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.

Bianca Davidde

Bianca Davidde

I completed post graduate medicine in 2011, during which I spent a student elective in a HIV clinic in Phnom Penh, Cambodia. Since graduation and fellowship I have worked in correctional health, a high HIV case load general practice and have recently commenced training to become a sexual health physician.

 

This was a session dedicated to addressing HIV in 4 main populations that have been identified as “key” around the world, including migrants, sex workers, men who have sex with men and people who inject drugs.  The studies presented had varied countries of origin which helped to demonstrate that key populations vary worldwide.

 

The first presentation presented data from the aMASE study to determine the rate of migrant acquisition of HIV in Spain. This was a multi-centre cross sectional study that collected data from both patient questionnaires and clinical notes in 6 regions around Spain of patients who had been diagnosed with HIV in the preceding five years and had lived in Spain for a minimum of six months at time of diagnosis.  A range of information was collected including socioeconomic, behavioural, migratory, previous HIV testing, CD4 and viral load levels and resulted in a statistical analysis to determine most likely time and place of acquisition.

 

 Of 710 participants, there was sufficient data to estimate time of acquisition for 685.  77% of the analysed respondents were men and 60% were MSM, 20% heterosexual women and 14% heterosexual men.  Median age was 35 years and median time in Spain was 9 years.  The region of origin were Europe 17%, Latin America 64%, Sub Saharan Africa 13% and others 6%, this trend is reflective of the large numbers of Latin American people migrating to Spain and so mirrors broader population trends.  A total of 72% of the sample were estimated to have acquired HIV whilst living in Spain.  Factors associated with post migratory acquisition were Latin American origin, younger age and increased duration of stay in Spain and the proportion was also higher in MSM.  This highlights 2 key populations that are being failed with regards to prevention, migrants (especially Latin American) and MSM and suggests who needs targeting in national prevention strategies, such as PrEP.

 

The second presentation presented data collected on transactional sex in MSM from Vancouver, Canada and has been blogged about by one of my colleagues, so I will only briefly touch on this presentation as it has been covered more extensively elsewhere.  The motivation for this study was to ascertain whether transactional sex in MSM is a causative factor in HIV transmission.  The study objectives were to determine prevalence of transactional sex events and evaluate temporal trends and consequences such as HIV risk or acquisition in a prospective cohort study.  Results of 690 participants and 8990 sexual events revealed that transactional sex was rare with 2.4% reporting receiving, 1.2% reporting giving, 0.3% reporting both giving and receiving.  To assess HIV risk, the investigators focussed on condomless anal sex and HIV concordance, discordance and unknown status and there was no statistically significant difference between these groups and whether they engaged in transactional sex or not.  Factors that did increase the risk of transactional sex included low income, loneliness, substance use of the partner (GHB and methamphetamine) and meeting online.

 

A third presentation of a study nested into France’s Ipergay study presented data about the suitability of on demand PrEP for chemsex participants.  The objectives of this sub study were to better characterise chemsex participants and study the association between engagement in chemsex and PrEP use.  Chemsex participants were found to be more likely to use anxiolytic medications, be sensation seeking and have increased numbers of sexual encounters.  They were also more likely to have condomless anal sex, hardcore sexual practices and perceive themselves to be at higher risk of HIV.  What was notable was that they were also more likely to use PrEP perhaps due to their justifiably perceived higher risk.

 

 

 

Fourth was a study from south Africa on health outcomes of children of female sex workers, who have about a 60% HIV prevalence rate.  This was undertaken in the form of a cross sectional study at sex work venues and mobile health centres from September 2015- February 2016.  The mothers completed a questionnaire and HIV testing.  The children were also tested for HIV and growth parameters measured.  Results demonstrated maternal HIV prevalence at 67.5% and ART at 63.6% and overall HIV prevalence in their children was 3%, rising to 4.5% in HIV positive mothers.  Full vaccine coverage decreased as the children got older and 27% of children’s growth was stunted, a reflection of their nutritional status.  This study really highlighted that health services for sex workers would be well placed to expand into caring for the children of their key population as well.

 

The Vietnamese DRIVE-IN study presented data on HIV and HCV incidence and risk in people who inject drugs in a longitudinal follow up of 204 eligible participants.  Of the 204, 105 were HCV positive only, 94 were negative for both HIV and HCV and 5 were HIV positive only.  No HIV seroconversions occurred during the 1 year follow up period but 18 HCV seroconversions occurred.  Factors associated with HCV seroconversion included more injections and being arrested. This data supported the perception that HIV was low in this population but also brought to light that HCV needs to be addressed as a priority for this population.

 

Finally, data from a Kirby institute run, multi-site Opposites Attract trial presented more data to support treatment as prevention in male serodiscordant couples.  A total of 358 couples enrolled worldwide and the total couple year follow up was 591 years.  During this time, 3 seroconversions occurred.  All 3 seroconversions reported condomless anal sex outside the principal relationship and phylogenetic analysis of the seroconverted participants and their principal partner demonstrated overwhelmingly that there were no linked transmissions.  The data demonstrated that in over 12,000 acts of condomless anal sex with a virally suppressed HIV positive partner and a HIV negative partner not on PrEP, there were no transmissions of HIV.

 

Tagged in: 2017 IAS Conference

 

Presented as part of the mixed bag “Co-chairs Choice “ session this study aimed to assess dolutegravir (DTG) in pregnancy. There are many benefits to DTG as treatment, highly effective, well tolerated, once daily with high barriers to resistance.  However, despite being a drug with many desirable qualities, the lack of data in pregnancy have resulted in DTG not being recommended in pregnancy by the WHO.  This study addresses some of the research shortfalls and compared pregnancy outcomes from patients who used EFV/TDF/FTC between August 2014 and August 2016 and those who used DTG/TDF/FTC from November 2016 to April 2017 

 

Much of the groundwork for this study was laid out by the Tsempano study, which demonstrated that EFV/TDF/FTC was associated with lower rates of any adverse birth outcomes as well as lower rates of severe adverse birth outcomes compared with other ART regimens (NVP/TDF/FTC, NVP/ZDV/3TC, LPV/r/TDF/FTC, LPV/r/ZDV/3TC).  A similar framework was adopted for the comparison of DTG/TDF/FTC with EFV/TDF/FTC in women who commence ART pregnancy.

 

Maternal demographics were well matched in both groups for age, employment, parity, gestational age at presentation, previous pregnancy losses and smoking and alcohol consumption.  They were also well matched with regards to the gestational age at which ART was commenced as well as their CD4 counts.

 

Outcomes were startlingly similar as listed below:

 

Total and severe adverse birth outcomes 34% in the DTG/TDF/FTC group, with 11% being a severe adverse birth outcome.

 

Total and severe adverse birth outcomes 35% in the EFV/TDF/FTC group, with 11% being a severe adverse birth outcome.

 

 

 

Birth at less than 37 weeks gestation 18% and less than 32 weeks gestation 4% in the DTG/TDF/FTC group

 

Birth at less than 37 weeks gestation 19% and less than 32 weeks gestation 4% in the EFV/TDF/FTC group

 

 

 

19% small for gestational age and 6% very small for gestational age in the DTG/TDF/FTC group

 

19% small for gestational age and 7% very small for gestational age in the EFV/TDF/FTC group

 

 

 

2.1% stillbirth in the DTG/TDF/FTC group

 

2.3% stillbirth in the EFV/TDF/FTC group

 

 

 

1 major congenital abnormality in the form of skeletal dysplasia in the EFV/TDF/FTC group

 

This preliminary data suggests that DTG may well be considered safe in pregnancy at some point but further research is needed in the following areas:

 

Birth outcomes associated with exposure to DTG from conception

 

Combination with other backbones eg ABC/3TC

 

Maternal viral load at delivery

 

Tagged in: 2017 IAS Conference

 

An important group of presentations today on STIs, a somewhat neglected area of discussion in HIV, despite evidence that people with higher rates of STIs are at increased risk of HIV and vice versa.

 

First presenter was Darren Russell from Australia presenting some background on the epidemiology of STIs.  First and foremost, the point was made that, if you do not test for it, you will not find it and then you cannot treat it (much like the first 90 with HIV!)  and that in contrast to HIV, testing, reporting and surveillance of STIs is inconsistent throughout the world, making STIs the “poor cousins“ of HIV. Given the international nature of the conference, epidemiological data from around the world was presented for STIs.  One slide demonstrated that in the early 20th century, as many people died from syphilis as did from HIV/AIDS at the height of the epidemic in the USA.  The incidence of syphilis from late last decade throughout the USA, Canada, Germany, Sweden, France, The United Kingdom and Australia was noted to have risen significantly in all countries and a special mention was made of the syphilis epidemic in Aboriginal and Torres Strait Islanders, a group in which we must try to do better if we are to close the gap.  This presentation ended on a high note with a success – the roll out of the HPV vaccine and the dramatic decrease of genital warts in vaccinated Australian women and eventually men.  I thought that ending on this information really served to demonstrate to the sexual health community what is really needed to stop epidemics – vaccine development.

 

Next Presenter was Scott McLelland from the United States who presented on STIs and susceptibility to infection.  We have known for some time that STIs place people at risk of HIV and vice versa but elucidating exact mechanisms has been challenging and interventions have not been as successful as previously hypothesised.  Yet more recent data has demonstrated significantly increased risk of HIV acquisition with HSV2, vaginal dysbiosis (bacterial vaginosis) and HPV due to the immune response.  For example, the site of HSV lesions has been shown to have high numbers of CD4 T cells and dendritic cells as does HPV infected mucosa, providing increased target cells for HIV virus.  How we use this information as a basis for further research, treatment and ultimately health policy remains to be seen.

 

Next was Connie Celum, also from the United States who presented on STIs in the era of TasP and PrEP.  One of the first and very important points made was that there is no evidence to indicate decreased efficacy of PrEP in users who have an STI – demonstrated in both iPrEx and Partners PrEP studies.  One caveat was that bacterial vaginosis may impact the efficacy of topical vaginal tenofovir.  The possibility of PrEP programs actually leading to a long-term reduction in STIs was brought up and the role of regular STI screens as part of PrEP use as well as the potential for STI PEP using doxycycline, presented as part of the ipergay study at CROI in early 2017 were both put forward as mechanisms to reduce the burden of STIs in PrEP users.  The model of STI testing, treatment and follow up was also addressed with reference to the Dean Street Express clinic in London with changes in service delivery proving effective in testing and treating more people in a shorter space of time and as mentioned previously – if you don’t test for it, you can’t treat it!

 

Last but not least was Cecile Bebear from France who gave a presentation called “should we fear antibiotic resistance for STIs?” with a focus on 4 bacterial STIs – Chlamydia trachomatis, Neisseria gonorrhoea, Treponema pallidum and Mycoplasma genitalium. For Chlamydia trachomatis, the concern for antimicrobial resistance (AMR) is low with the organism remaining sensitive to tetracyclines, macrolides and quinolones and only very rare cases of macrolide resistance being reported, so as Chlamydia trachomatis remains the most common bacterial STI, it also remains very easy to treat. Neisseria gonorrhoea is the complete opposite however, with resistance to almost every agent ever used against it since about the 1930s.  First line treatment with combined antibiotics of two classes has held Neisseria gonorrhoea at bay, but for how long?  Extended cephalosporin resistance rates in this organism, where there is resistance monitoring range from 0.1% to 30 % in various parts of the world (up to 5% in Australia).  Azithromycin resistance ranges from 2-8% across the world, fluoroquinolone resistance 30%- 50% and tetracycline resistance more than 50%.  New treatments are in development pipelines but the ideal way to tackle this organism would be through a vaccine.  Syphilis remains relatively easy to treat with penicillin or doxycycline but does have a high prevalence of azithromycin resistance (84% in Australia).  Finally, the new kid on the block, somewhat of a problem child, Mycoplasma genitalium, tetracyclines demonstrate poor levels of eradication but no resistance characterised, macrolide resistance is widespread, between 43% and 63% in Australia and there is acquired resistance to the agreed upon second line treatment moxifloxacin, ranging from 4.5% in the UK to 47% in Japan.  Unfortunately, this problematic organism did not generate much discussion nor were potential third line agents for consensus discussed.  Certainly more research needs to be done in regards to this organism and consistent guidelines on management are required.

 

Tagged in: 2017 IAS Conference

This was an interesting presentation in that it gave the perspective of what is happening with wider access to PrEP throughout the world, which I think is highly relevant given the recent submission for PrEP to be listed on the PBS in Australia.  It started off with a taste of the WHO's PrEP implementation tool that will be officially launched at IAS 2017 and aims to provide a framework for implementation of PrEP on current evidence to a number of stakeholders, including clinicians, pharmacists, consumers and regulatory officials.

 

The talk then moved on to what is happening in France, home of the ipergay study which demonstrated that on demand PrEP was efficacious.  France has been successful in implementing access to PrEP within their state funded health system and as of early 2017 had almost 3,000 people on PrEP.  The main PrEP users in France are men who have sex with men (MSM), however a strong campaign is underway to ensure other target groups within France, namely migrant and transgender women are aware of PrEP and their access to it.

 

Moving on to South Africa and their implementation which has focussed on two main priority groups within their context – commercial sex workers (CSW) and MSM.  Between June 2016 to June 2017, over 30,000 CSW had HIV tests and almost 2,000 were initiated on PrEP.  For the same time period, over 1,000 MSM had HIV tests and over 200 were initiated on PrEP.  Both these groups demonstrated a fairly low overall uptake with CSW uptake around 7% and MSM uptake around 21%.  The uptake within the transgender community was reported to be very low.  Possible reasons for low uptake included stigma of ART medications, even if used as PrEP and inconvenience of clinic setting and to address the latter issue, the model of care has evolved into a nurse or peer led service with more convenient hours, locations and mobility.  What is great to see is in South Africa, of the people who do commence PrEP, about 75% are women and about 75% are between the ages of 19-34, which means that PrEP is getting to the groups that need it most, as in Africa the highest growing incidence is in women and young people.  Another great outcome is the sheer number of HIV tests that are being done – a step towards addressing the first 90.

 

Next stop on our world tour -  England, home of the PROUD study, famously interrupted due to the high 9% incidence of HIV in the delayed PrEP group.   There are currently an estimated 6,000 people on PrEP in England, the main source is via personal importation as the NHS were not willing to fund the addition of PrEP onto the national formulary, despite two court cases to compel them to do so.  Some funding for limited places has been made available recently.  Further compelling evidence for PrEP was presented in a 42% reduction of new HIV cases between 2015 and 2016, demonstrating that PrEP is benefiting both the individual and the greater MSM community. What is interesting is that the incidence of Chlamydia has been reported as stable when compared to the number of increased tests and that cases of Gonorrhoea have indeed decreased by 24% between 2015 and 2016.  No data for syphilis was presented at this talk.  The data for the bacterial STIs is encouraging as opponents of PrEP may use the rise in these STIs as an argument against widespread implementation.

 

Over to Australia and the achievement of the 90, 90, 90 targets was highlighted yet despite this, stable notifications of new infections and a significant proportion of new infections (70-80%) in MSM demonstrated that in the Australian context, meeting 90, 90, 90 is just not enough to make a population impact. Small PrEP demonstration projects in 2014 in New South Wales, Victoria and Queensland with combined numbers of around 500 participants demonstrated that high risk MSM (demonstrated by high rates of other STIs on enrolment) were willing to enrol and uptake PrEP with good adherence. The taxpayer funded health system in Australia calls for a cost effective and high impact upscaling and as such, high risk MSM remain the target population.  This upscaling was implemented in the EPIC trial in NSW which has over 6,000 paticipants in that state alone (other state trials only got a brief mention but an estimated further 6,000 places combined are available).  Data presented from EPIC demonstrates that the target group of MSM is being reached, that those under 20 years of age are under represented and that Gonorrhoea notifications are continuing an upwards trend, one that was already underway before the implementation of wider use of PrEP. It appears that new HIV infections have decreased with a reported 29% reduction in all diagnoses and a 43%reduction in early diagnoses in the first quarter of 2017, compared with the previous five year average, however more data over more time is required to ascertain if this is a significant trend as a result of PrEP.  Given these figures, there is great hope that PrEP will be PBS listed and the outcome of recent submissions to the PBAC will be known late August 2017.

 

Kenya presented next and identified their target populations as CSW, MSM and adolescent girls and young women (AGYW).  There have been significant milestones in Kenya’s upscaling since July 2016, including national guidelines, approval of generics and a national PrEP scale up launch in May 2017.  Further information presented revealed uptake in a number of groups beyond the initial three target groups, including partners of sex workers, men who have multiple female partners and serodiscordant couples.  A substantial media campaign was adopted to attempt to address the stigma with PrEP use in Kenya.

 

Last but not least was a presentation on the target group of adolescent girls and young women, an over represented group in Africa with some dramatic figures – 1000 young African women dying from HIV related illnesses every day in 2015, 90% of all new infections in 15-19 year olds in girls are in Southern Africa and only a 6% reduction in HIV in women 15-24 from 2010 to 2015.  HIV in pregnant women in South Africa was also startlingly high with an 11.5 % prevalence in women under 16 years attending for antenatal care all the way up to 51.9% in those over 25 years of age.  Given the high numbers in women and pregnancy, an assessment of PrEP in a sexual health and reproductive clinic seting has been commenced and between March 2016 and February 2017, 429 women were offered PrEP with a 61% uptake, a 67.8% retention rate with adherence being reported as 90% based on pill counts.  This demonstration project will hopefully inform how to roll out PrEP to South African women in sexual health and reproductive clinics in the very near future as it is desperately needed.

 

PrEP for adolescent girls and young women in Africa is NOT a luxury we can afford to withold 

 

 

 

Tagged in: 2017 IAS Conference