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.

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

Hi everyone,

Another excellent plenary session presentation with some clinically relevant findings for primary care physicians and health promotion teams.


Associate professor Jo-Ann Passmore, from the University of Cape Town where she also heads the Genital mucosal and STI laboratory gave an insightful presentation on the association between genital tract immunity and susceptibility to HIV and STIs. Her group investigated the markers of inflammation on the vaginal mucosal in South African women prior to acquisition of HIV infection. They measured series of inflammatory cytokines and did screening for the STIs.

Interestingly, they found increased levels of pro inflammatory cytokines MIP-1β, MIP-1α which bind to the HIV CCR5 and facilitate entry of the HIV into the target cells. They also reported increased levels IP-10, and IL-8. The risk of HIV acquisition was significantly higher in women with evidence of genital inflammation, defined by at least 5 of the 9 inflammatory cytokines being raised [OR 3.2; 95% CI 1.3-7.9].

Amongst the STIs, Chlamydia was found to be the most inflammatory STI, while Bacterial Vaginosis was also associated with upregulation of the pro inflammatory cytokines.

Another interesting finding from this study was that there was no correlation between increased genital inflammatory cytokines and the plasma inflammatory cytokines. The clinical and immunological relevance of this finding in the context of long term immune activation for those who eventually got infected and the utility of genital inflammatory markers in clinical practice remains to be seen.


Although this study was done in South Africa, The findings further highlight the importance of screening for STIs particularly for all sexually active adolescents and women even in Australian setting. Also for health care providers and health promotion teams working with CALD communities  and Sex workers, this is work provide another compelling evidence for ramping up STI testing campaigns in order to reduce the new transmission of HIV  and other STIs.


 It is known that combined  Antiretroviral therapy(cART) before 6 weeks of age results in low levels of HIV .

If treatment starts before 1 year of age, there is a median of 4 copies at 10 yrs of age.

Treatment within first 48 hrs(& first 4 days of life), most will clear the virus before 4 months. Most of the virus is in transient memory cells, rather than central memory cells. The Missisipi baby was infected in utero but treatment was initiated within 31 hrs and discontinued at 18 mths. This baby remained in remission for 28 mths off cART.

Very early cART alters HIV persistence in children. It limits pro viral and replication competent reservoirs.

In adults, we are still determining what undetectable HIV (when being treated with ART) really means., and how early is the ideal time to start treatment.

In HIV infection, there is a massive expansion of HIV in lymphoid tissue but with treatment it is undetectable in the bloodstream. There may be decreased intracellulardrug concentration in lymphatic tissue And this may be the site of clones that expand when cART is stopped or if there is poor adherence to ART medications for whatever reason

A much anticipated late breaking presentation from London was a study looking at transmission from people with Viral Loads less than 200, who practised condomless sex. No observed transmission occurred, where on accepted transmission data 86 new infections would have been expected in the study group. BUT the science cautioned that they could still be concealing a 32% 10 year transmission risk, if related to receptive anal sex. The caution was a worst case statistic, because of the small numbers so far studied. It seems there will be a lot of explaining to patients to be done in the next few months when the study results get widely published. Researcher's suggestion, tell them "our best guess is its safe, but we can't tell you that", isn't  very useful. Abstract #153LB

Tagged in: CROI2014

The best posters of the day were invited to give a 5 minute speech. I thought these two might interest you as much as they did me.

1)      Charpentier et al looked at outcomes of patients in France with a HIV VL 20 copies/ml (a level many labs are now using), to those with a VL 20-50copies/ml over a 12 months period. She found no statistical evidence of a greater likelihood of ultimately developing virological failure in the 20-50 copies/ml group. Although I did think the power was pretty limited to detect this... In fact 4% of the <20 groups developed virological failure, compared to 8% of the 20-50 group... So no p-value to speak of, but maybe something that merits repeating with bigger numbers.

2)      Finally Gale et al presented a study looking at whether we need to bother measuring CD4 counts after viral suppression. This was actually done by Chilton et al in the UK some years ago, but this study was from the US. In short, if the VL as undetectable, if the CD4 was >300 then less than 1% of patients had a CD4 drop to below 200 cells over 4 yrs of follow-up. Further CD4 did not lead to any clinical management changes that could not have been foreseen by measuring only VL. The exceptions of course are those starting IFN therapy, chemotherapy or other medical reasons to expect a possible CD4 drop that might require prophylaxis of OIs.

Tagged in: AIDS 2012

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