I'll admit it now, I haven't been very up-to-date on the global approach to Hep C treatment, but this talk really brought me up to speed on several aspects.  Thanks to Dr Joseph Doyle for the great talk.

Global elimination targets

• worldwide there are 2.2 million people living with HCV/HIV
• compares to 37 million with HIV
• odds of HCV infection were 6 times higher in people living with HIV
• most HepC infections related to IVDU but some sexual exposure
• target: 30% reduction in infections and 10% reduction in deaths (2020)

Elements needed for elimination

• testing
• early reliable diagnosis, frequent, regular testing
• diagnosis allows connection with care and treatment, education, harm minimisation services, may influence at risk behaviour
• Aust: recommends annual testing
• but may need to recommend more frequent testing if we are serious about eradication
• access to care
• recent PBS listing to many new drugs
• all are now interferon free
• community prescribing is encouraged (after discussion with ID/hepatology)
• no disease stage or drug/alcohol restrictions
• in contrast to other countries where drugs are restricted to those with cirrhosis
• this restriction would reduce costs but won't make much headway into eradication
• effective treatment
• sofosbuvir and velpatasvir (single pill regimen for all genotypes)
• others are also coming soon
• treating people at risk
• target IVDU, MSM, born overseas in HPC
• cost effective allocation
• $20k for 4 years of extra life (if severe disease)
• $60k for 6 years of extra life (if mild disease)
• therefore even cost-effective to treat mild disease
• many other options cost >$20k per year of life
• harm reduction strategies
• HCV vaccine

The medications are effective, the funding is there to support the clinicians, patients are enthusiastic and actively seeking treatment - I think this is an exciting time for Hep C management and I am optimistic to see the future.

The single-most incredible presentation at the conference.  Dr Kedar Narayan presented on some amazing new technology which is allowing us to view HIV in a completely different light.  He somehow managed to explain what is clearly a very complex principle in simple terms, and with plenty of humour sprinkled in.

• traditional electron microscopy only provides a 2D image of the cell
• focuses ion beam scanning electron microscopy (FIB-SEM) allows a 3D image
• the tissue is embedded in a block, with the side face open to the EM scanning
• the FIB laser is used to slice the tissue (like a deli slicer/cutting a loaf of bread) to reveal the next layer of the tissue
• the EM can then image the 2nd layer
• this is repeated 1000s of times to obtain a stack of images (like a CT scan)
• computer software can generate a 3D image of the tissue, including all the internal structures
• FIB-SEM can be applied to HIV
• HIV virons actually use small tunnels from intracellular vesicles to the extracellular surface to escape the cell
• this explains why other studies have found that the pH of vesicles were less acidic than expected (i.e. because they were actually connected to the extracellular membrane)
• virological synapse
• the dendritic cell actually “hugs” the T cell
• rather than individual projections from the cell, the DC actually has lasagne like sheets (veils) to connect with the T cell
• this excludes all drugs since the synapse is covered by the “hug”
• often thought that the T cell is passive in receiving antigen presentation
• not so - they can reach into the DC to sample for virus

What an exciting start to the day (following on from the excellent trainee sessions this morning), and the rest of the session proved equally as informative...stay tuned

Quick update on a presentation by John McAllister

• if source VL is undetectable, then PEP is no longer recommended
• however, do need to discuss the reliability of the history of undetectable VL
• Truvada should be used for PEP
• avoid tenofovir and lamivudine (although cheaper)
• 3-drug PEP
• if 3 drugs are needed, then stick with dolutegravir (ALT increases by 22%), raltegravir or rilpiravine

Jason Asselin gave us a comprehensive overview of ACCESS, a national registry designed to pull HIV data from primary health care, sexual health clinic and the laboratory.

• his study included patients who had viral load testing within the last 12 months
• the last VL for the year was used to allow more patients to be included
• VL testiong as part of diagnosis was excluded
• demographics: males were older, females were younger
• results
• citeria for undetectable VL was met for 71% (2009) => 87% (2014)
• porportion of patients with a high viral load decreased
• similar outcomes for M vs F
• patients <40 years old were less like to achieve VL suppression compared to older patients
• weaknesses
• does not capture patients who did not engage in health service
• ACCESS will be rolled out nationally from Jul ’16 – Jun’19
• we can look forward to more comprehensive data

The opening plenary talk was given by Dr Valarie Delpech, who outlined the progress towards attaining treatment for all.

• the UNAIDS target for 2020 is 90-90-90
• 90% of patients diagnosed
• 90% of patients on ART
• 90% with viral suppression
• data from Levi et al (2016) showed
• 54% diagnosed, 41% on ART and 32% virally suppressed (2015 data)
• there appears to be a great disparity in the countries able to achieve this with many having poor rates of diagnosis and hence low rates of treatment/viral suppression
• Dublin declaration data: EU/EEA countries are performing better than the non-EU/EEA
• to date, no country has met the 90-90-90 goal (except claimed by Sweden)
• a major issue
• most countries have very little data about actual rates (even 4 decades into the epidemic)
• there is variation with data sources and quality of definitions/standard methodology

I haven't come across PrEP before - it is not easily accessible in Western Australia, although a few patients have obtained it through personal importation.  Hence, the sessions on PrEP were of particular importance to me as I'm sure they will be filtering through to WA very soon.  In particular I enjoyed the summary by Prof Jared Baeten, and I've tried to summarise my learning points below.  I've combined two of his talks into one.

Firstly, I love this quote that he put up (forgotten who said it though): all truth goes through three phases: it is ridiculed, violently opposed, and then accepted as self-evident.

• PrEP works: those who had tenofovir in their system had a >90% reduction in HIV transmission
• PrEP works for high risk patients
• a single agent may work as well as dual agents (e.g. TDF only = 85%, TDF/FTC = 93%)
• adherers adhere
• not everyone used PrEP, but those who did use it tended to be consistent users
• non-adherers rarely started adhering
• there wasn't much change in behaviour after 1 month
• surprisingly, real world effectiveness was better than efficacy in the studies
• ?adherence was better in real life than in the trials
• PrEP  has several additional benefits
• decreased anxiety
• increased communication and trust
• increased sexual pleasure and intimacy
• chance of developing eGRF <70 while on PrEP if your baseline is >90 is extremely small
• rising STI rates in the US have been happening for a while, even before the introduction of PrEP
• PrEP works even when STIs are present

Most of the informal feedback I've heard before today has been that PrEP is associated with an increase in STIs but if the data above is applicable to Australia, then perhaps that isn't quite true.  I think the evidence if favour of PrEP is mounting, and the major obstacle in Australia is probably the cost-benefit ratio...

Dr James Ward gave us a thought provoking opening speech outlining the recent increase (i.e. divergence) of HIV infection rates among Aboriginal and Torres Strait Islanders compared with the general population.  Here are the take home messages from the talk:

• initially rates of HIV infection were similar between Indigenous and TSI, but numbers are now increasing
• 2015 marked the highest rate of new diagnoses (n=38)
• new diagnoses of HIV are occurring in rural and remote areas, which has never been seen before
• why?
• background: young, more mobile, more regional
• risks: injecting equipment, high background of STIs
• success in non-indigenous diagnosis
• failure to engage with community
• how to improve?
• increasing workforce rather than downsizing
• timely surveillance data (absurd that we deal with 2015 data in Nov 2016)
• implementation of a national KPIs reportable for STIs by Aboriginal PHC
• change to AHC, make STI/BBV checks more mandatory
• Medicare items specific to BBV/STIs
• improved testing strategies
• only 32% of people with a positive STI screen had an HIV test within 30 days

I found the session a real eye opener and saw that there were plenty of areas that we could improve in. Simply increasing the rigor at which we conduct testing would seemingly make a big difference.