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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.
Catherine completed medicine at Monash University graduating with honours in 1997. She completed an intern year in Alice Springs Hospital and entered GP training in 2000. She has worked in rural and remote Australia, completing a Masters in Public Health at Sydney University and further degrees in rural medicine.
She became Medical Director of Gateway Health Wodonga in 2015 and has overseen the development of the Multicultural Clinic which sees all the newly arrived refugees to the region and the development of the first locally based HIV clinic at Gateway Health. She is also the doctor for Clinic 35 Gateway Health which is a sexual health clinic for young people and oversaw the development of the Medical Termination of Pregnancy program within Clinic 35 in 2014. Since then the clinic has performed more than 200 medical terminations and is seen as one of the leading innovators in the provision of medical termination of pregnancy in a rural GP setting.
As my patients are almost all women living with HIV and from an African background who are very keen to breastfeed, this session was number one on my priorities to attend despite being yet an another 7:30am presentation.
The presentation was set up as a debate with three speakers although in the end, they all came to a similar conclusion!
First was Dr Karoline Aebi-Popp (Obstetrician & Gynecologist (German Certification), MSc Infectious Diseases – Specialized in Sexually Transmitted Diseases, University Hospital Bern,Switzerland) who presented the ‘no’ side to the question of whether all women is Europe living with HIV should breastfeed.
Worldwide, 150,000 child acquired HIV in 2015 and 1/3 of these acquired their infection from breastfeeding. Karoline did point out that most of this data is African data. Although ART reduces the HIV RNA levels in breastmilk it does not reduce the HIV DNA levels. There is also evidence that some of the ARTs get into the breastmilk such as dolutegravir which has a number of potential problems.
There is a risk of resistance if the infant is exposed to monotherapy via breastmilk. Also there is a risk of delayed diagnosis if the baby is positive but ART suppresses virus replication.
Overall from meta-analysis of all evidence of breast feeding in HIV, the risk of MTCT ranges from 0.9%-4%. Is this acceptable given in high income countries we have access to a safe alternative which has a 0% risk of MTCT?
Dr Fiona Lyons (consultant in Genitourinary and HIV Medicine at the GUIDE clinic, St. James’s Hospital, Dublin, Ireland)spoke next on the ‘yes’ side supporting breastfeeding in maternal HIV.
Fiona made the important point that we need to not just look at MTCT but also benefits of breastfeeding for the mother including breast cancer reduction. She produced evidence that MTCT in an ideal world is less than 1%. All the evidence we have about breastfeeding in maternal HIV Infection includes low and middle income countries which may not reflect the potential in high income countries with safe access to bottle feeding and high quality HIV care and follow up.
She emphasised a patient-centred approach with an individual assessment of each patient and their circumstances.
Dr Karina Butler O’Connell (UCD Clinical Professor of Paediatrics, Consultant Paediatrician and Infectious Diseases Specialist at Our Lady's Children's Hospital and The Children's University Hospital, Temple Street, Dublin, Ireland) spoke on behalf of the child. She presented the evidence that in low and middle income countries breastfeeding actually decreases mortality due to reduction in diarrheal diseases. However even in high income countries, the MTCT rate was not zero. This risk goes up when we look at actual behaviour not just ideal behaviour (reduced adherence to medication, lost to follow up etc). For the child, she felt this was not an acceptable risk.
I look forward to the prospective cohort study that Karoline is involved in looking at transmission rates in breastfeeding.
- have an individualised approach
- Better to allow the mother to discuss in an open environment.
- We need more research particularly around models for supporting breastfeeding
Below is a link to Lancet review and discussion of evidence in HIV and breastfeeding.
I found this session particularly good and relevant to my practice. I also ran into my mentor for HIV prescribing Dr Olga Vujovic from The Alfred hospital in Melbourne at this session which was great!
Diagnosis and management of Non-Alcoholic Steatohepatitis (NASH) & Non-Alcoholic Fatty Liver Disease (NAFLD)
Sanjay Bhagany (Consultant physician/honorary senior lecturer in infectious diseases/HIV medicine, Royal Free Hospital, London)
Emmanuel Tsochatzis (senior clinical lecturer and consultant hepatologist at the UCL Institute for Liver and Digestive Health, Royal Free Hospital, London)
Abnormal liver function (LFT) tests and fatty liver are common and often frustrating conditions seen in general practice. I see a significant number of refugees who have abnormal LFTs as well as managing patients with HIV with abnormal LFTs so I was keen to get up early and get to this 7:30am lecture!
Emmanuel made the important point that you can’t always trust the LFTs. Patients can have severe disease with normal LFTs and grossly abnormal LFTs with just fatty liver. It is important to remember that 25% of general population have fatty liver and of those 10% develop cirrhosis.
Fibroscan is important for assessing liver disease although for rural towns like mine, access can be an issue.
Steatosis can cause over-estimation of stiffness in fibroscan. A fibroscan result of >7 is worrying in fatty liver.
Important strategies for everyone with abnormal LFTs associated with fatty liver include addressing CVD risk factors, there is some evidence this will improve fatty liver. We should be considering fatty liver as part of metabolic syndrome, commonly managed in general practice. Extending this to people living with HIV is important as HIV infection itself is fibrogenic.
NASH/NAFLD prevalence in people living HIV is up to 50%. Causes are multifactorial and include HAART therapy plus virus protein inflammation plus lifestyle. Nadir CD4 count and a history of use of older HIV drugs are risk factors for liver disease.
Emmanuel talked about some of the difficulties in making an accurate diagnosis of fatty liver including ultrasound and biological markers as well as non-invasive assessments, all of which have their limitations.
Treatment essentially is about reducing weight including bariatric surgery if appropriate. Emmanuel talked about the experimental use of maroviroc.
In summary, it is important to think of NASH/NAFLD in people living with HIV and reducing cardiovascular risk and monitoring of progression are the mainstay of management.
Sophie Flavell and John White spoke about STI testing and screening.
Important take home messages for me in this session were:
- don’t forget that for MSM with high risk behaviour Hep C is sexually transmitted ie make sure you include it in STI screen in high risk populations
- consider using doxycycline 200mg as a stat dose as PEP for chlamydia and syphilis (70% reduction in infections)
- pooled testing (3 samples in one pot)for chlamydia/gonorrhoea NAAT is currently not funded but saves money and will form part of the future in STI testing
At the first day of the European AIDS Conference 2017, Sharon Walmsley (Senior Scientist at Toronto General Hospital Research Institute) spoke at the Women Against Viruses in Europe (WAVE) forum.
When considering ART in women it is important to remember the following
- drug trials rarely include significant numbers of women
- Consider whether woman is planning pregnancy (remember safety of ART in pregnancy is generally based on expert opinion not on evidence)
- Consider drug interactions with contraception
- Stribild and Genvoya not recommended in pregnancy as elvitegravir and cobicistat do not cross placenta so baby is not getting adequate levels
- Consider co-morbidity in the older woman especially around menopause and cardiovascular risk
- HIV and/or ARTs seem to cause higher rates of early menopause
- Women living with HIV have higher rates of CVD AND women living with HIV have higher rates of osteoporotic fractures
- Therefore consider change of ART at menopause
- Women represent >50% of people living with HIV however studies of drugs for HIV rarely include significant numbers of women.
More to come...