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.

Anthony Elias

Anthony Elias

I am an Australian infectious disease registrar working over in HIV in Dili, East Timor. Timor remains a low prevelence country, however in recent years incidence has steadily risen. Here I am part of a team caring for half of the patients in the country on treatment. Work here has been challenging with limited resources, an unreliable supply chain and Significant administrative hurdles. I hope to eventually return to Australia and complete infectious disease training.

Perhaps one of the more applicable talks to my experience in Timor was that given by Angela Kelly-hanku on challenges reaching key populations.

In PNG its the church groups who often provide the most stable centers to operate health interventions (different from in Timor), and these have been the platforms from which international health programs have carried out their work.

The talk highlighted just how difficult it is to define the 'key populations', in that many who present to these facilities do so as they want non-judgmental care, where they won't be labelled as MSM, FSW and so on. I do wonder if its similar to the situation in Timor, where the largest HIV clinic is run by a private NGO, as foreign staff (and possibly church groups) are less likely to know the patient and their family. But defining key population can be so much more difficult... An interesting chart revealed 20% of MSM in PNG didn't report being attracted to men, and 40% reported being attracted to both men and women. We may see a fairly similar pattern in Timor once again, where a high percentage of the MSM (>50%) also have female partners. This could be related to the horrendous level of stigma and discrimination against them.

However the ultimate answer to the question are we reaching the key populations was revealed towards the end of the presentation with confronting statistics revealing 60% of the MSM in PNG have never been tested, and 32% of the FSW have never been tested. So No is the answer.

I can't imagine Timor is any better with the horrendous supply chain issues encountered over the past year...

Posted by on in Public Health and Prevention

One of the biggest challenges facing health now and into the future is that of antimicrobial resistance, and Monica Lahra from the WHO did a fantastic job at outlining the issue.

Almost 40 years ago the specialty of infectious diseases seemed almost dead as it looked as if mankind had won the battle against microbes. However this was short lived as natural selection ensured antibiotics were no longer our golden bullet. 

Though to some degree antimicrobial resistance is an inevitable consequence of antibiotic use, antibiotic abuse has certainly led the problem to explode throughout the world.  Inappropriate use in hospital, community health facilities, pharmacies and pharmaceutical companies (dumping in water ways) and agricultural practices (fish farms and livestock) have all been the major of drivers of this. Furthermore travel has ensured these organisms are spread throughout the world. For example Poor antibiotic practices have ensured the subcontinent is riddled with ESBL enterobacteriaceae. A survey of Swedish travelers stools before and after returning from the subcontinent showed extremely high carry rates of ESBL after returning to Sweden, often persisting for months. It's tragic to hear now Colistin resistance is being widely seen, particularly in livestock.

So how do we tackle this growing problem? Not easily. Improving awareness and education to healthcare providers so they rationalize and appropriately prescribe antibiotics is key. Restricting over the counter purchasing of antibiotics must accompany this. Increased surveillance and research is also a key to understanding the patterns, distribution and resistance profiles of such organisms. And finally better hygiene practices must continue to be promoted. 

 

Self- Testing in HIV has been a controversial topic, and from my experience with HIV in Timor I have been very skeptical it could be successfully performed

The two sessions from Mark Bloch and Anna Mcnulty however demonstrated to me that it was a feasible and potentially useful option. First Mark Bloch spoke of advantages/disadvantages of self testing.

Self testing has many advantages. It gives people the opportunity to test themselves in a comfortable environment at a time convenient to them. They no longer need to wait hours or days for a result. And no longer need to risk multiple people being aware of their diagnosis (huge issue with health facilities in Timor, as everyone is related). It also has the added benefit of being easy to do in rural and remote environments, where people would have to travel hours to get tested.

However one of my worries has been the quality of the results, as they are more likely to be inaccurate when performed by untrained hands. on top of this the person undergoing the test may not undergo adequate counselling/ understand the significance of a positive result. Another concern centers around missing numerous other crucial tests that would also routinely be performed in those receiving HIV tests. 

To my surprise however 88% of those performing a rapid HIV test in NSW were capable of following all the steps correctly (though i imagine this would be much less in a place with poor education like Timor).

Following Marks talk Anna Mcnulty went on to discuss self testing with Dry Blood Spot. This had the advantage of being easy to post to and from the household of those being tested and relatively easy to be performed. It's had a slow uptake in NSW, though the MSM community seem to be catching on.

Self-testing definitely has an important role in reaching those communities who would not otherwise engage in healthcare due to concern of confidentiality, convenience, geography and comfort.

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The first ASHM conference symposium on HTLV-1 proved extremely insightful, as to date I had very limited exposure and education related to it. 

Numerous speakers provided comprehensive talks on this largely neglected topic. Two back to back session from Graham Taylor (imperial college London( and Fabiola Martin (University of Queensland) provided a great overview of the topic.

Like HIV, HTLV-1 is a retrovirus, however rather than triggering cell death, HTLV-1 triggers Tcells to proliferate. Where there is cell proliferation there is risk of mutations and malignancy. The virus is transmitted sexually, vertically and through blood exposure. 95% of those exposed are asymptomatic, however the virus may cause a HTLV-1 inflammatory syndrome characterized primarily by myelopathy. It also can eventually cause T cell leukemias/ lymphomas (emphasizing the importance of monitoring LDH and lymphocytes). Median age of onset of symptoms is 48, though its usually 7 years before patient present.

In terms of treatment steroids have shown improvement in the short term (though usually benefit does not persist beyond 4 wks. More recent studies suggest a role for steroid sparing agents with one showing at 48wks slight improvement in spasticity, walk tests, CSF VL and no increase in VL in the blood. Other more promising agents include AZT (for unclear reasons) in combination with interferon, and in Japan monoclonal antibodies to ccr4.

My take home message from this is in patients from endemic areas who present with a myelopathy, a HTLV-1 should be part of my routine work up.

Philip Keen, the co-ordinator of the NHPPP from the Kirby Institute gave a fairly uplifting presentation on the diagnosis and care cascade in NSW in relation to meeting the 90:90:90 targets.

90:90:90 refers to the WHOs aim of having 90% of PLHIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment with a suppressed viral load. The result would be 73% of PLHIV having a suppressed viral load. 

No surprise Sweden were the first to reach this goal, with 78.8% of PLHIV with a suppressed viral load. Numerous other countries have subsequently demonstrated >73% of the PLHIV with suppressed viral loads.

In Australia we fall short of this mark. However in 2016 health surveillance of the data from NSW had some interesting results. 91.3% of PLHIV were Diagnosed, 92% of these were receiving treatment and 94.5% of those on treatment had a suppressed VL. This equated to 79.3 % of PLHIV in NSW having a suppressed Viral load. Better than Sweden.

So this proves what I have always said, that NSW should form its own country as the rest of the country is holding us back... In all honesty it demonstrates there is probably a significant amount of inequality between various parts of Australia in accessing appropriate care. 

A very interesting talk today by Assoc Prof Adam Bourne today addressing many of the benefits and obstacles to reducing harm in sexual practices.

I thought the most fascinating part of the talk centered around the use of Pre-Exposure Prophylaxis (PrEP). Recently I heard there were almost as many people on PrEP in Sydney as there are on ARV's. 

The talk was largely a positive spin on PrEP, highlighting how it has improved sexual experiences, and undoubtedly the mental well being of the MSM community as well as PLHIV. However many of the issues associated with its use stem from peoples reluctance to use PrEP due to the stigma associated with taking HIV medication. I felt however the issues of condoms no longer being used by many using PrEP in casual relationships was understated. PrEP no doubt has a crucial role in prevention of transmission of HIV in serodiscordant couples, however if our message is its safe to have sex with multiple casual partners if we have an undetectable viral load or PrEP in the absence of other safe sex practices (such as condoms), the rates of other STIs will skyrocket. I know many of these STI's are treatable, though with resistance patterns seen in gonorrhea and the latency often seen in syphilis we could have serious problems on our hands. Not to mention the fact there is resistant HIV virus in the community, to which the PrEP may be ineffective. The message we should put out is yes PrEP can protect you from HIV (in most instances), however it doesn't mean that if you shouldn't use a condom if you're going to have sex with multiple casual partners. 

PrEP is still a long way off in East Timor (my current place of work), though as health resources improve could be a great aid to reduce HIV transmission.

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