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.

George Forgan Smith

George Forgan Smith

Dr George Forgan-Smith is a GP based in Melbourne’s busy CBD. He has a busy practice where he has a high focus on gay men’s health, sexual health, HIV care and PrEP.


When he’s not at work he is an active blogger, video creator and enjoys the opportunity to travel and educate at leather, kink and gay men’s health events on sexuality, health and kink safety


 

Brief video created today to help increase knowledge for GP's on DRE exam for MSM.

I hope that it will help increase knowledge and practice within the GP community. I will continue to share response from my GP colleagues as they interact with the video.

Very excited to be able to walk away from this conference with some proactive resources that may help increase knowledge beyond those who attended.

Specail thanks to Dr Ong for this time and expert knowledge.

Learn more here: http://www.anal.org.au/clinician

Current criminal law is lagging behind our latest understandings of how HIV is transmitted, and more importantly *not* transmitted.

Take for example law in the Northern Terratory. NT currently hosts a "spitting laws" that can allow for invasive HIV testing in instances of spitting. This is despite zero evidence to demonstrate potential HIV transmission via saliva.  It is clear that current judicial law Is well behind the evidence when it comes to public safety with regards to HIV transmission.

As part of this weeks ASHM conference 2016 a position statement has been launched to help guide law towards the latest research and medical data on the current risks of HIV transmission.

I applaude the release of this position and hope that this may be quickly picked up within our judcial systems moving away from legislation and towards eudcation and health based interventions.

http://theconversation.com/australian-law-needs-a-refresher-on-the-science-of-hiv-transmission-68225

https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement

 

 

Notes from talk:

The most recent syphiils outbreak in northern Australia highlights the vulnerability of this community due to isolation, reduced access to services and poor engagement with the health communities. 

Advances in HIV treatment in Australia has created an obvious divide with increased HIV diagnosis in ATSI communities. While non ATSI HIV diagnosis are mainly in men who have sex with men, this only accounts for 50% of the case load in ATSI communities.

Increased IV drug use appears to be fueling this with reduced access to programs such as needle exchange.

Canadian modeling is sobering if we continue on this same path.

 

Notes from talk stream:

Men who have sex with men are at significant risk of HPV related anal cancers. HIV negative MSM are at an estimated 20-40x risk and HIV positive MSM are at 100x risk!

HPV Vaccination is going to be one of the keys to help reduce this risk.

Many gay men have not been vaccinated for HPV and this is a key move that can help reduce incidence.

Many doctors are not doing DRE to examine for any anal lumps.

It's a simple, cheap and easy exam and can detect early anal cancers from 0.5cm diameter.

Early detection <1cm results in simple surgical treatment that may not require chemo/radiation therapy.

HIV positive men should be offered annual DRE and HIV neg MSM every 1-3 years.

Anal Paps are difficult to fully roll out at the moment as many early anal changes will self regress. Sadly anal colposcopy services are very limited currently making this one area of bottle neck in evaluation of early anal lesions.

This session has absolutely changed the way I will be practicing and caring for my MSM patients from today!

Good resource for futher information for both doctors and clients is this site created by AFAO.

http://www.thebottomline.org.au

Sexual Health Day 2 Mycoplasma Genitalium

Mycoplasma Genitalium has a high prevalence within the community, is difficult to test for as well as being tricky to treat.

Mycoplasma his the cause of significant pathology including intrauterine death, PID, proctitis, cervicitis and urethritis.

Traditional treatment has always been 1g Azithromycin however there is significant emerging macrolide resistance. This leaves only Moxyfloxacin which is hard enough for me to get as a GP and Pristinamycin currently needing to be imported from France...

As reported we clearly need better testing that includes resistance screening as well as new antibiotics to target this insidious infection.

Mycoplasma Genitalium has certainly been a "theme" at this event and will be a a big part of future work. I have to wonder if MG infection may have been responsible for the many cases of "sterile prostatitis" I have treated over the years...

Watch this space.

 

Great session today on rectal Chlamydia today that will definitely change the way I practice.

Rectal Chlamydia can be difficult to treat with increased resistance to Azithromycin (1g stat dose = 86% cure)...

99% cure has been noted with Doxycycline 100mg BD for 7 days.

Question is should this change my practice?

For me the answer is perhaps..

If compliance is an issue it may be best to do 1g Azithromycin and then test for cure. Have Doxycycline in backup for failure.

In severe symptoms and/or the patient is likely to have good compliance I thing I will change to the Doxy regime, also with test for cure...

 

 

Sexual Health Day 2 Pharyngeal Gonorrhoea

Very interesting presentation of transmission of pharyngeal Gonnorhoea.

Take home points:

  • Not likely to be transmitted penis -> throat / throat -> penis as commonly thought.
  • Likley transmission mechanism is via saliva. Deep kissing and use of saliva as lube
  • Pharyngeal Gonorrhoea may be more prevalent in younger age groups due to higher levels of kissing
  • Worth rendering to ensure swab of throat even if clients report no oral sex 
  • ?could anallingus be a mode of rectal transmission?
  • Daily antibacterial gargle may greatly reduce load of pharyngeal Gonorrhoea

Professor Mark Hayter University of Hull

"Stronger Than The Sum Of Our Whole"

Notes: 

  • The one stop shop can be a great opportunity to offer comprehensive care for clients with multiple needs.
  • Great chance to consider combining sexual health and reproductive health, sexual health and drug and alcohol services.
  • Colocation within schools may be useful and a great chance to "be where the market is". Evidence points to importance of need for concominnent quality sexual health education as well as branding as "health" service rather than "sexual health " service to reduce stigma.
  • May not apply to all markets, ie gay men appear to prefer traditional GUM/Sexual Health services.

Personal reflections:

My question is, isn't the GP in the perfect position for this? I wonder if there are GP's similar to myself who feel strongly to be able to step up and provide these levels of services. 

Currently this reflects my own practice however I wonder if there are other GP's who have similar passions.

Will these services limit communication between teams and loss of some patients to primary care?

 

Sexual Health Conference Day 2  Gollow Lecture IT and sexual health

Notes: 

Young people are very engaged with new technology. 

  • It's available 24/7
  • Offers privacy
  • It can be interactive
  • Is able to offer sexual content.
  • For me it's highly valuable for education

New self check in stations have proven to increase efficiency with faster interactions, data being more accurate as well as allowing more patients to be seen.

Other interventions include medical software prompt systems which have proven to increase opportunisitc testing of STI's such as Chalmydia.

Computer system grouping of tests and guidance has also increased syphilis testing in HIV positive clients and checking for missed tests such as rectal swabs for Gonorrhoea / Chlamydia in MSM.

SMS recall systems have increased testing regularity and recall for test for cure.

Resources:

http://amaze.org
http://data.kirby.unsw.edu.au

 

Notes:

Family Planning Victoria have had a large push to help create resources to help youth engage and navigate sexual health services and education.

Through alliance with schools, medical teams, educators the moderation and creation of resources has been helpful in engaging youth.

Resources can be reviewed at rse.fpv.org.au

There is very little in the way of research into non heteronormative society in indigenous and TSI communities. Sadly the majority of portrayals are hyper sexualised and not representative of diverse gender queer indigenous community.

This is a need to understand that "gay health" is not exclusive to "sexual heath" there are many more areas of gay male health to be explored and engaged.

Many GLBTI youth are suffering significant prejudicial treatment within the schooling system. Schools without GLBTI policy have increased self harm, suicide, bullying and harassment of GLBTI youth. 

GLBTI policy has been shown to be protective creating increased safety as well as retention in the school system.

Many trans and intersex youth are leaving schooling rather than face the poor treatment while attending school. Trans and intersex youth are at higher risk of self harm, suicide, and bullying.

Many resources provided at schools are not inclusive and not helpful or supportive for GLBTI youth.

Current estimates are that 2 in every 30 students are GLBTI and without inclusion they can be lost to schooling, bullied, self harm and be at risk of attempted and completed suicide.

Notes:

HPV associate with 90% of anal cancers. HPV 16/18 is associated with 92% of the HPV related anal cancers.

Being an MSM associated with a 40x risk of HPV anal cancer. Being an MSM who is living with HIV shows an up to 100x risk of HPV related anal cancers. 

Spanc study showed that while a percentage of men with self clear of anal HPV infection this is less likely with HPV 16 infection.

Despite treatment guidelines not recommending HPV vaccination in men older than 26 the SPANC study showed that many older men have not been exposed to HPV 16. This opens the suggestion that vaccination with 9 strain HPV vaccine may offer benefit beyond the age of 26.

The indigenous population of Australia is suffering with disproportionate levels of STI's. Risk are 3x for Chlamydia, 18 x for Gonorrhoea, 4x for Syphilis. Barriers have been identified for men to get STI testing including lack of information as well as culturally appropriate male health workers to engage with clients for testing.

There has been a significant rise in Syphilis infections within Northern Australia's indigenous population. Rates are similar in men and women in the younger age group 15-29 years old. 

Given risk of congenital syphilis and intrauterine death a robust testing campaign has been initiated to test all women of child rearing age as well as intensive screening of pregnant women. 

Testing in pregnancy includes up to 5 tests during pregnancy and if a female has had a positive test she is then testing monthly till delivery and followed for 3 months post delivery to ensure no reinfections.

Notes:

Indigenous Australians have a disproportionally higher levels of Chlamydia and Gonorrhoea compared to non indigenous Australians.

Point of care testing for Chlamydia and Gonorrhoea in Remote North Australia has proven to be highly effective in ensuring rapid diagnosis and treatment of those infected.

POC testing has reduced time to treat from average of 19 days down to 72% less than 3 days and the majority treated in under 7 days.

Real time testing of Ciprofloxacin resistance in Gonorrhoea is emerging with testing for genetic patterns associated with Ciprofloxacin sensitivity as well as resistance.

Pristinamycin is a novel new antibiotic with dual action that may prove to be helpful in treating macrolide resistant Mycoplasma Genitalium. In doses of 2- 4 g daily it has shown 75% cure rate in previously failed treatment of MG. Pristinamycin has shown an acceptable side effect profile and safety in pregnancy when given unknowingly.

New PCR test kits are emerging that allow the detection of MG resistance detecting 5 different genetic markers. This may aid better directly therapies for treatment of MG.

Changes in vaginal microbiota have been associated with increased risk of bacterial vaginosis.

Risk factors include, reduced levels of lactobacillus, increased exposure to different vaginal flora via new sexual partners, high levels of Gardinerella as well as changes in stability and increased diversity of the vaginal flora.

Female partners of men diagnosed with pathogen negative non-gonococcal urethritis should be notified, tested and ?treated with review of partners data showing increased rates of symptoms in female partners (60%) and a 12% association with PID.

 

Notes: 

Khadija Gbla's key note speech was fantastic. She has highlighted the importance of unpacking and going back to absolute basics when talking sexual health with people from culturally diverse backgrounds.

She has provided a timely reminder that we as Australian's are able to take many things for granted that others across the world, and those who have come to Australia may not have had access to.

It's important we "check out privilege" and stop to think were we are coming from as well as the recipient of the information we are hoping to share our message with.

 

Basil Donovan has well earned being the first recipient of the ASHA Distinguished Service Award. His work in sexual health with many of Australia and the world's best has changed the climate of sexual health in many profound ways.

 

Amber D'Souza gave a fantastic synopsis of the effects of the HPV virus in both men and women. She has highlighted the importance of vaccination for HPV and how prevention is an important tool against HPV given it's high impact on men who have sex with men in particular those living with HIV.

I was genuinely surprised to learn of heterosexual transmission of HPV, female to male, lead to marked rates of oropharyngeal cancers in heterosexual males.

Amber also gave a great preparation to later presentations on the relationship of HPV with anal cancers in MSM.

 

Finally a synopsis of new HPV screening, vaccination guidelines. Look out for 2 doses of 9 strain HPV vaccines in the near future.

Changes to cervical screening guidelines also highlighted.

Further details available at Future Changes To Cervical Screening Guidelines. 

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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