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.

Kasha Singh

Kasha Singh

I am an Infectious Diseases physician with interests in HIV, TB and hepatitis. I have spent 10 years working overseas in the UK and in clinical trials in developing country settings. I am currently completing a PhD in HIV-Hepatitis B, looking at the pathogenesis of liver disease in this patient group.

The trainees presentations were a highlight of the conference for me - some fascinating cases, presented superbly with an audience including some great HIV clinicians made for a stimulating and highly educational session. It would have been easy to continue the discussion on any of these cases for a good few more hours. 

The first case, from the Alfred Hospital was of a young man recently arrived in Australia who presented with a rash and pulmonary infiltrates. The rash was eventually found to be histoplasma - an important diagnosis to consider, although much more common in other parts of the world, locally acquired cases have been reported.

The next case, from Perth, was of another visitor, this time from Zimbabwe, who was diagnosed with HIV after presenting with sinus pain. Investigations found haemophagocytic lymphohistiocytosis, and she was diagnosed with orbital NK/T cell lymphoma. Due to her status as a visitor, there were issues associated with payment. Whilst her HIV care was paid for as an STI according to a state government undertaking, therapy for the cancer proved an entirely different matter. She was given second line therapy in order to contain costs. On her return to Zimbabwe, again HIV treatment was easily available, however the treatment of the cancer was again not possible and she died 3 months after her return.

A case of gummatous tertiary syphilis, presenting as lesions on the back and arm was presented from inner city Sydney. Again, advanced HIV, known this time for a number of years but untreated, was present, however in this case, syphilis had also been diagnosed on numerous occasions over recent years but remained only partially treated. The case presented numerous issues including diagnosis and management of tertiary syphilis, the difficulties in managing patients with psychiatric comorbidities as well as complex social circumstances and itinerancy. This was a sobering reminder of the difficulties that are faced in clinical practise, and the presentation ended with the case being unresolved (patient absconded with partial syphilis treatment and having not picked up ongoing HIV medication scripts).

Finally, from the Royal Melbourne Hospital, another late presenting individual with advanced immunosuppression, newly diagnosed with HIV and started on treatment, presented to hospital with cryptococcal meningitis, and, despite treatment, deteriorated with multiorgan failure and decreased conscious state in ICU. Fortunately, he recovered to be discharged well form hospital a number of weeks later. The analysis focused on the reasons behind the deterioration in health after treatment commencement, with the most likely explanation believed to be unmasking cryptococcal IRS. An important question about whether rates of IRS are increased on INSTi was raised, with George Behrens- guest from Germany and one of the judges of the session, announcing an impending clinical trial in severely immunocompromised new presenters starting on treatment , comparing rates of IRS on treatment with PIs compared with integrase inhibitors.

In addition to the medical complexities of the cases, common themes including late presentation, still a not infrequent problem, and the difficulties in management associated with challenging socio-demographic circumstances, including itinerancy, psycho-social issues, and medicare -eligibility. 

Plenty to think about.

 

The team from SAHMRI gave 3 presentations of which this was the last. The first 2 gave a good background to the service. Katy who gave this talk is from Broome so covers the Kimberley region.

This presentation was focused on the 'Young Deadly and Syphilis Free" campaign, recently launched.

The campaign aimed to deliver a multifaceted education and awareness campaign of syphilis in remote areas.

Components included media strategy (examples were played - including a great TV commercial and a radio advertisements linking themes of testing during pregnancy and general testing - which are also being developed in local languages), posters and education materials, social media strategy (e.g. Facebook page) and health service engagement strategy (e.g. there is a fortnightly electronic email for HCW. (available via This email address is being protected from spambots. You need JavaScript enabled to view it. )).

(Syphilis animation and other TV ads are available on youtube, website, links from Facebook page).

Stakeholders were young people and health services/youth agencies.

Considering social media - 

Of Facebook posts the video postings seem to be the most popular/greatest % reach of all postings. 'Likes' of the page were mainly 25-34yo group. 

Some data presented about some remote FB pages not being active, and that Facebook use potentially overstated in initial consultations.

Diva Chat messaging is popular in remote areas - provided free by Telstra. This platform offers advertisement appearing as banners across young people. Diva Chat is used for hooking up a lot there. High usage rates across stages.

Instagram - less engagement with this group of young people in remote areas. Only 54 followers. Bust most popular on this is condemn, and lubricious.

YDSF website went live on 1st July this year (part of the STI/BBV page). Some google analytics were presented for this page including channels of traffic as well as visitors.

In this presentation by UNSW post-doc fellow Dr Anupriya Aggarwal investigated the role of actin in HIV cell to cell spread. They looked at the structure of actin and the location of HIV in the actin during viral assembly and then budding. HIV was found more often on the curved actin surface versus the shaft area, and intersects with the ARP 2/3 pathway. The presentation was full of amazing 3-D representations of their findings - with the localisation of HIV eGFP shown in relation to the cell surface.

Damian Purcell from the Doherty presented the story of discovery of a new latency reversing agent, currently in the process of in vitro experimentation using ex-vivo patient cells.

Background : agents trialled to reverse latency - PKC activators, HDAC inhibitors, Bromodomain inhibitors 

So why is a novel agent needed? Lack of specificity and potency have been a significant problem in agents to date, many of which have come from the cancer field.

For example - Work from the Purcell/Lewin labs at the Doherty has shown that HDACi inhibit expression of key HIV splicing proteins; HDAC inhibitors in vitro are unable to elucidate expression of spliced RNA, Bromodomain inhibitors on the other hand are able to lead to spliced RNA; this is rescued by the addition of tat protein.

Considering Tat ; 'the master regulator of HIV-1' - (its own latency reversing agent?) by recruiting kinases which help in regulating HIV transcription and RNA processing; Tat itself is also acetylated (thereby activated), which could also be inhibited by HDACi.

So what about new drugs? What do we want?

Tat can be produced without production of virus - and is a neuropathic protein...

Tat induces LTR specific response specifically. This is important, considering that what we are interested in is finding HIV-specific activation pathway 

A drug library was screened to look for agents activating tat in particular - (WEHI) - resulting in an amidothiazole being identified. Medicinal chemistry was used to increase the potency of the compound, which was then trailed on patient derived cells (obtained via leukapheresis); this demonstrated reactivation.

These agents appear to synergise strongly with bromodomain inhibitors (currently trailed agents) and appear to be specific for HIV reactivation, and selective for HIV containing cells that contain tat. 

HIV notifications in Aboriginal and Torres Strait Islander people are increasing, mainly in men, mainly in Qld, particularly in regional settings. Transmission risks are different - higher IDU and heterosexual transmission than amongst non-Indigenous individuals.

Prof Russell spoke specifically about the FNQ outbreak that commenced in Cairns in 2014, and now included about 30 new diagnoses. Coinfections with syphilis is common (known concurrent / preceding syphilis outbreak in the area), and there have been 5 deaths due to congenital syphilis. This in itself is staggering. Mainly young men (2 women). Mainly MSM though not gay-identifying. Only sporadic IDU use has been reported. New cases include Cape York, Torres Strait and NT. 

Various measures that could be considered with regard to prevention were considered -systemically in this talk by this experienced HIV clinician who has been based in Cairns now for many years.

  • Condom use (Fagan et al 2010, self reported behaviours suggest similar rates of condom use amongst this group to others, but younger sexual debut, more sexual partners. Unlikely to be able to significantly increase.
  • Test and Treat - low level of HIV testing overall in this group.'Nth QLD STI Action Plan' covers syphilis but not really HIV; Good testing of male prisoners in Cairns, reasonable antenatally for women. Adult and young peoples health checks now include HIV testing. Consider - point of care testing (ALere Determine accessibility)
  • TasP - the presenter considers this is the most likely strategy to reduce onward transmission but costly, logistics etc.

A Recent audit found significant numbers at high risk of onward HIV transmission in need of case mx and extra support. Significant need for individualised management. Leaks from the Treatment cascade are myriad/multiple - shame/stigma, as well as more mundane issues like money/transport availability, poor hosing, low health literacy, alcohol and drug use. Furthermore this is generally a highly mobile population.

  • PrEP - Pessimism was expressed for this as a strategy in this group, despite 3% prevalence amongst the 2000 on PrEP in QLD. (4% population indigenous). However most in SE Qld.Pessimism because of low health literacy, most don't identify as gay; more engagement and culturally appropriate PrEP promotion is needed. On-demand PrEP or long-actin PrEP may be more appropriate in this target group.
  • Health promotion is urgently required-  but some ideas are circulating/in development.

The importance of knowing your epidemic is illustrated dramatically here.

Presentation from Jenny Hoy (Alfred Hospital) regarding enmeshing quality improvement in routine HIV care.

One example covered was syphilis testing - recommendation that syphilis serology done with all HIV VL tests. Initial audit suggested only 25% or less of cases of HIV VL testing at Alfred were accompanied by syphilis serology. Response with clinician education was effective in improving testing to around 50%, but not durably so (decreased again after 1year). An individual clinician audit approach was more effective, and changing the system to 'opt out' (syphilis testing needed to be crossed off for it not to be done), proved successful. Food for thought regarding clinician behaviour and testing algorithms. When is an 'opt out' approach appropriate? And how does it impact on clinician responsibilities, patient rights, and health outcomes?

The next example presented by Prof Hoy concerned screening and management of HT by clinicians. Re-education was required for doctors to check BP, however surprise to realise that re-education was subsequently required to get them to do anything about the results! An important lesson, particularly given the aging HIV infected population - as presented in the last session I attended (Theme B this morning at 11:15am) and the new comorbidity focus on illnesses associated with aging including cardiovascular disease, bone mineral density changes and cognitive impairment. HIV clinician-gerontologists are uncommon, but at the very least HIV clinicians need to expand their skill sets to optimise their abilities to manage the new comorbidities seen in their patient populations. 

One of the important messages presented in this talk was that audit is required to improve quality of care - shortfalls may thereby be identified at individual provider, setting and state and national levels. Quality improvement needs to be integrated into care. To make changes durable however is the next challenge.

Finally, she discussed the barriers to Quality of care, for example-the importance of setting standards for quality, as is seen in the European Guidelines , for care of PLHIV. We do not have these in Australian guidelines at the moment. 

"Quality of life is inextricably linked to the quality of care that we deliver".

Minding the Gap - Daryl O'Donnell, CEO AFAO Australia

Spoke of the exciting possibility of ending HIV transmission in Australia. The laying down of a blueprint of this and the potential savings in new infections and healthcare costs in Australia. The challenge of what is needed to achieve this is sobering and important - commitment, money, vision and importantly more research into knowing our epidemic and the strategies that will work in our setting to achieve this. A great step by the government to consider this and be involved. An inspiring vision to work towards. 

RT @hepqld: Curing #hepatitis C is easy, and no longer needs a specialist to prescribe treatment. Community doctors play a pivotal role in…

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