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.

Day 1 plenaries continued the themes from the opening ceremony with great presentations on the epidemiology of the HIV pandemic from Steffanie Strathdee.  Alex Coutinho presented data on Universal Access, the stage beyond the 90:90:90 target set by WHO.  Some countries in Africa appear to be close to passing these benchmarks include Rwanda and Swaziland.  There were few dry eyes at the conference as Edwin Cameron, a South African judge described his life living openly as a HIV positive gay man since 1986.  He introduced his godson who has been living with HIV since his birth 22 years.

 

A Clinical highlight of the morning was the PrEP:New Drugs session.  Robert Grant (TUAC01) reviewed the risk of drug resistance versus the benefit of HIV prevention across 6 randomized clinical trials and one demonstration project. This study was of great interest to those doctors involved in PrEP studies in Australia so the take home messages are:

 

1)    FTC resistance occurred in 10 who received FTC/TDF PrEP, including 33% (5/15) with acute infection when starting PrEP, and in 3% (5/157) with established infection. 98 infections were prevented giving 10 (98/10) infections prevented for every FTC resistant infection.

2)    Tenofovir resistance occurred in 1 who received TDF PrEP, including 10% (1/10) with acute infection when starting PrEP, and none (of 90) with established infection. 53 infections were prevented by TDF PrEP giving 1 (53/1) infection prevented for every tenofovir resistant infection

3)    A screen for acute viral symptoms in PrEP assessments led to deferral of PrEP among 30 of 1603 (1.9%) of whom 2 (6.7%) were found to have acute HIV.  No acute infections were missed using this screen.

 

At the Late Breaker session K Rawlings presented data on the uptake of PrEP in the USA with almost 80 000 people started PrEP in the USA to end of 2915, 76% are men.  No data was available on longer term use of PrEP.

 

The highlight of the ‘Cancer and HIV’ program was a presentation by Andrew Grulich from Kirby Anal cancer in people with HIV  (TUSY0803).

To summarise.  Historically anal cancer is the third most common cancer in HIV +ve males after KS and lymphoma. In heterosexual males it is 10 x more common, in gay males it is 50 X more common than the general population with an incidence of up to 100 / 100  000. Following ART and CD4 recovery there has been a rapid decline in KS and lymphoma but only a slight decline in anal cancer incidence which remains high even with normal CD4.

In terms of primary prevention HPV vaccination results in a 75% reduction in high grade disease in young gay men but preliminary data did not show that it was effective in males older than 26 although further studies are needed.

In terms of secondary prevention – screening and treatment is complicated by the 75% prevalence of high risk virus with 30 – 40% high grade disease but there appears to be less progression to cancer compared with cervical disease.   Treatment pathways are currently uncertain. In comparison to colposcopy anosocpy requires much more training.

In terms of tertiary prevention detection of anal cancer remains controversial with some recommendations to perform annual PR examinations

In the epidemiology session Alison Rodger presented results from the PARTNER (TUAC0206).  This prospective, observational study enrolled 1166 HIV sero-discordant couples who reported condomless sex and HIV-1 RNA load suppressed to less than 200 copies/mL.  1166 enrolled couples, 548 heterosexual and 340 MSM provided had a median follow-up of 1.3 years. No HIV transmissions occurred within the studied couples.  11 infections occurred from ‘unlinked’ partners. This gave rate of within-couple HIV transmission of zero with upper 95% confidence limit of 0.30/100 couple-years, and for condomless anal sex 95% CI of 0.71 per 100 couple-years of follow-up. These results are very encouraging in terms of the tremendous value of treatment as prevention.

 

I am quite of fan of the EACS guidelines particularly for co-morbidities and on  Friday they had a session detailing what's new in version 8.0 October 2015

 
1. ART
presented by Jose Gatell
 
The Europeans are now on page with everyone else with treatment recommended for all persons with established HIV infection regardless of CD4 count, the exception being elite controllers. This brings all 4 sets of guidelines into agreeance: DHHS, IAS and WHO (see table below)
 
b2ap3_thumbnail_Initiation-of-ART.jpg
The next slide is the greatly revised table of what to start with. Key features are:
 
13 regimens downsized to 6 (the DHHS guidelines have just 5, choosing to omit TDF/FTC/RPV whereas the EACS retains)
 
Increasing number of INSTI based regimens
 
Rentention of one each of PI and NNRTI based regimens
 
b2ap3_thumbnail_Initial-Combination-Regimens.jpg
 
 
2. PrEP
also presented by Jose Gatel
 
A whole new chapter in the guidelines and the only set of guidelines internationally to recommend "on demand" PrEP based on IPERGAY. CDC guidelines continue to support daily PrEP.  Ongoing concerns about on demand PrEP include reduced efficacy in MSM who may not be having sex as often as the men in IPERGAY or who may not be as good as tailoring Intermittent PrEP usage to perceived risk of sexual events as the men in IPERGAY. You can't deny the overall efficacy however. Will intermittent PrEP's inclusion in guidelines influence your practice?
 
 
b2ap3_thumbnail_PrEP.jpg
 
 
3. HCV/HBV Co-infection
Presented by Jurgen Rockstroh
 
Highly revised guidelines on which HCV patients to treat with DAAs. See the photo below. This table is adapted from the EASL guidelines drawn up in May and includes a footnote on who should be given priority for treatment independent of liver fibrosis. I think it is very forward thinking as it includes those with debilitating fatigue, extra hepatic manifestations such as cryoglobulinaemia and those at risk of HCV transmission including high risk MSMs. It is interesting how we are beginning to apply TasP principles to HCV. Applying TasP principles to the co-infection epidemic in MSM is not unfounded because it is concentrated and networked but it is probably unfounded in monoinfection with only an estimated 40% people diagnosed in most countries. 
 
 
b2ap3_thumbnail_Mngt-Chronic-HVCHIV-Coinfection.jpg
 
Finally the table below is a useful clinical tool for monitoring acute HCV infection. Spontaneous clearance is indicated by viral decay in log at certain time points. It still  lists IFN/RBV as treatment for acute infection only because we have not yet consolidated the evidence base for this with DAAs. That is about to change however with 3 datasets of DAA treatment in acute HCV almost ready. 
 
 
b2ap3_thumbnail_Acute-HCV.jpg
 
 
 
 
 
 
Tagged in: EACS2015

Whilst we should try to adhere to the guidelines re PJP prophylaxis for sustained CD4 counts over 200 prior to cessation, there is enough reason to not panick if a patient is having difficulty being adherent , and

1. Their CD4 count is above 100, or

2. Their CD4 count is above 75 and the viral load is <400

and

3. They do not have underlying lung disease or another cause of immunodeficiency.

This particularly useful to have in mind for those patients with difficulty with adherence and a Bactrim allergy! It might be easier to prioritise another medication as opposed to upset rapport by trying to administer pentamidine or atovaquone which are less efficacious.

Tagged in: EACS2015

 

After two fascinating talks by Dr. Patrick Mallon and Dr. Geoff Symonds around great medical strides being developed, another facet of care and project development shone in the plenary session.

 

Andrew Jolivette’s elegant talk brought focus back to how we as practitioners and researchers can widen our perspective by weaving past social constructs, acknowledgement of generational impact and group solidarity into how we view and address health concerns in today’s world - especially in light of how our world's cultures are blending and evolving.

 

This session tied in quite nicely with James Blanchard’s talk and ‘Mega Model’, exploring windows of opportunity and individual timeline trajectories. Jolivette goes further, asking us to examine windows of opportunity and change for past generations – to include the impact our own previous generations have made on Indigenous cultural practice and social perception of self and others.

 

Again, the one-size-fits-all approach is noted as not working. Jolivette encourages us to work inclusively and collaboratively alongside groups to build community solidarity and ‘weave’ projects to improve outcomes in health and well-being.  He argues the incorporation of research justice and Indigenous methodologies can help build better programs while challenging identity and behavioural categorisations that continue to pigeonhole gender, sexuality and multiracial individuals/ populations.

 

In an interesting train of thought, he also asks we approach research as an act of ceremony to build cohesiveness while remembering the context some indigenous populations view research and how they benefit from projects.

 

Jolivette also notes the importance of peace of mind and the acceptance of disease as a process of healing –and that healing is an ongoing process of wellness.

 

I think there are strong parallels to be drawn between Native American experiences and the situations Australian Aboriginal peoples face. There is great potential for us to better tailor programs and I will be paying particular attention to what is happening in the gaps and blank spaces in program frameworks and research.

 

Andrew Jolivette’s talk today challenges all of us to examine the dynamics in public health programs and process implementation – and most importantly, finally acknowledge individual difference as a societal contribution rather than a hurdle.

Tagged in: HIVAIDS2015

The important ARV guidelines session featured 4 speakers and a discussion/scenario panel

We STARTed (sorry) with the START study preliminary results by Jenny Hoy. Jenny discussed the data we've all been looking at since it was released in May. Essentially, we can now confidently recommend ARV for all people diagnosed with HIV, regardless of CD4. The study was ceased early due the strength of results in both AIDS and Non-AIDS complications in the immediate ARV arm. The benefits were maintained regardless of age, gender, race, world location and CD4 and VL at entry to study. Worldwide ARV recommendations have updated accordingly. 

Next speaker was Julian Elliott who reminded us of other studies (TEMPRANO & CASCADE) which have shown similar data in terms of treatment benefit at higher CD4s. Understandably, the number needed to treat is greater with high CD4 counts.

As chair of the ASHM HIV guidelines, Julian re-iterated that the decision to start ARV, while recommended in all HIV infected patients, should be a patient & clinician collaboration. 

Mark Boyd was then tasked with summarising why the integrase inhibitors (InSTIs) are now first-line drugs. Pivotal and open label studies over the last few years have left no doubt that raltegravir, and more recently dolutegravir, show non-inferior (and often superior) efficacy, with minimal side effect profiles and a fairly high barrier to resistance. The tolerability of the InSTIs really make them an appealing option for almost everyone.

James McMahon concluded the formal presentations running through the important changes based on the updated DHHS guidelines. In short, Efavirenz - gold standard for a decade - is on the out due to side effects (dreams, dizziness, rash). In actual fact, it's been on the out for a while and prescribers have been updating accordingly, however the official recommendations have now followed suit. James spoke about Darunavir, a PI worth considering, but not reimbursable on the PBS criteria as a first line agent. 

The scenario based panel followed with the abacavir CV risk a main topic for discussion. The jury is still out. Most of us are not keen to prescribe abacavir, and thus Triumeq, if the CV Framingham risk is a concern.

Thanks for a good session! 

 

Tagged in: HIVAIDS2015

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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