At the close of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, faculty members Dr. Charles Boucher and Dr. Patrick Chung-Ki Li quickly presented a few slides showing the breakdown of who attended the conference.

An interesting point (I think) is that as a nurse, many presenters stated that to instigate new ways of working, reaching vulnerable populations and rolling out PrEP, nurses would be the backbone of the work force. Yet, only 5% of the attendees were nurses. To get nurses onboard and understand why they are expected to step up and lead these innovations, more need to attend conferences like #APACC2017.

At one particular session of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, Dr. Dan Kuritzkes (Harvard Medical School, USA) started his presentation by asking the question, 'Why do we need new drugs?'

The answers being:

• Side effects of current therapies.
• Long term toxicities of current ART.
• Resistance issues.
• Need for less frequent dosing.

He then went on to discuss new medications in development/trials.

DORAVIRINE (NNRTI) — This drug is active against HIV carrying the common NNRTI resistance mutations, it has low potential for drug-drug interactions and has the same efficacy as Effavirenz.

BICTEGRAVIR (INSTI) — Active against wild-type and strains carrying the common INSTI resistance mutations.

Dan went on to discuss the pros and cons of different types of treatment delivery such as injectables.

Pros                                               Cons

Monthly dosing                                 The injection itself may put clients off

More convenient                               Long term tolerability

Less internal stigma                          Long half life

Better adherance                              Cannot be self-administered

An interesting snippet was that TRUVADA is being researched as an injectable. This ties in with Dr. Zhang's presentation who stated that TRUVADA as a single tablet wasnt available in China and called for a new way to deliver this medication especially in the setting of PrEP. Dan mentioned a few other drugs in development but didnt elaborate much on them. These being:

IBALIZUMAB, FOSTEMSAVIR and PRO140.

The summary of Dr. Kuritzkes' session is:

• There are new drugs in several classes undergoing clinical trials.
• Different delivery systems are being researched.
• Novel viral and cellular targets are being explored rather than the traditional classes.
• 2 Drug ART regimens could became the norm rather than 3 drug ART.

This session was delivered by Dr. Andrew Grulich (Kirby Institute, Australia).

Dr. Grulich began by stating that, 'We know PrEP works'. He presented some short soundbytes about lessons learned from PrEP trials in Australia.

-PrEP quickly attracts very high-risk gay men.

-There was high levels of adherance (proven by drug monitoring testing).

-This cohort has high levels of STI's (showing their relative HIV risk).

-No HIV seroconversions seen in about 500 person-years.

As Australia has a concentreated epidemic (~0.1% prevalence in general population v ≤15% in MSM in urban centres), the most impact that PrEP will make is to target high risk MSM. Andrew presented a model that showed that if the high risk MSM group were saturated with PrEP users, it would result in much lower incidences of HIV plus it would have a herd immmunity effect on those in the same sexual networks but not exhibiting as high risk taking behaviour.

Andrew discussed the EPIC study. He discussed how some clinics workloads were much increased due to the amount of MSM on PrEP attending their clinics. This showed that innovation was required to ensure the services continued whilst under great pressure.Thes innovations included:

-Peer led education pre-consent sessions.

-Same day PrEP precriptions.

-Nurse led dispensing/care requiriung only once or twice yearly medical review.

Dr. Grulich asked the question, 'Will PrEP end HIV?' His answer was that whilst safer sex practices and TasP has resulted in stable HIV prevalnce in NSW, it hasnt showed a reduction. He displayed a slide that showed that since the PrEP study was rolled out, HIV prevalnce has REDUCED by 23% in the second half of 2016 in NSW. He did warn that it is too early yet to say PrEP is the reason. More data and time past is required.

He concluded by saying that should PrEP be rolled out as a national startegy, federal government subsidy would be required. The cost may not be as high as first thought as the PBS is considering an application for generic Truvada to be added as a PrEP treatment.

Recruiting people into HIV services
Panus Na Nakorn

The breakout session PA_9 was entitled, 'Innovative HIV testing, prevention and care service delivery models' with the first speaker Dr. Panus Na Nakorn presenting a session entitled, 'Recruiting people into HIV services: ebooking'. He told us that this model of care was Thailand-based where their 90-90-90 figures were 82-72-79 in 2014. The 90-90-90 is an indicator of how well countries are providing HIV treatment. It represents the percentage of people diagnosed-the percentage of those people on treatment-the percentage of those who are virally suppressed. He broke those figures down for MSM and they were poor reading as 19-37-65.

The speaker then discussed the Thai national strategic framework to end AIDS. He discussed current (offline) interventions where peer to peer and social networks are the most common way of trying to get get people to attend for testing. The speaker highlighted an interesting fact about internet use in Thailand - MSM and TransFemales spent more time on the Internet than other groups. To capitalise on this, a MSM specific site was created called 'Adam's Love Site'. This site was very well accessed and resulted in 20000 visitors to clinics for HIV and STI testing. This result showed that the internet could be a way of reaching MSM and getting them tested and into treatment. Dr. Nakorn explained how the ebooking system worked. After logging into the website, the client took a quick survey about any risk taking behaviours. If any were highlighted, they would be offered a test at a centre of their choosing and at a time/date convenient to them. The client filled out a form online and this gave the client a unique code. This code was sent to the centre they had chosen so when the client attended the centre already knew why they were there. Confidentiality was therefore maintained throughout. 
Dr. Nakorn completed his session by saying that ICT and social media needs to be embraced as way to reach key populations in this age of technology.

This sentiment has also been echoed by DR. Chris Beyrer who in a discussion session yesterday said (not verbatim) '...services need to go where the people are. Thats where the outreach principle came from. People now live in a virtual world. That's where the services need to go.'

Wise words.

This area was addressed by two speakers, these being Fujie Zhang and Martin Choo. Dr. Zhang is a medical practitioner whilst Mr. Choo is a social scientist.

Both discussed barriers to care from their respective viewpoints and whilst many barriers are common to my practice in Australia; others were alien to me. For instance, all the classes of ARV and the individual medications within those classes are not all available in China. Truvada is a single medication that isn't available. How can PrEP be rolled out if Truvada isn't available? Dr. Zhang didn't elaborate on why this was the case and I suspect the reasons are beyond the scope of this blog. He did mention that there was a need to develop new ways of delivering PrEP so as to ensure people at risk within China (and other Pacific-Asia countries) can access it.

Mr. Choo talked about barriers from a community level. He gave examples of negative experiences endured by HIV positive MSM/Transgender people which he states are not isolated instances in certain S.E. Asia cities where conservative attitudes to non-binary gender/sexuality exist. He spoke about an episode of a breach of confidentiality and made quite an interesting point around the funding of services by NGOs. The point being its all well and good providing money for services, but if there is no infrastructure built in to ensure confidentiality, breaches will happen.

Where is the epidemic heading?

Chris Beyrer opened the conference with his keynote lecture entitled, HIV/AIDS in the Asia Pacific: Where is the epidemic heading?

He told us that there are 5.1 million people living with HIV in the region, this is actually a low prevalence. However, only 41% living with HIV get ARV, which means approximately 3 million of these people don't get access to ARV's. Only Australia provides adequate levels of ARV coverage.

He went on to discuss key populations, these were defined as groups who have a disproportionate burden of HIV and also lack access to services, including:

• MSM (Men who have Sex with Men)
• Sex workers of all genders
• Trans females who have sex with men
• Discordant partners
• Adolescents from all key populations

He went on to tell us that the major strain of HIV has also changed within the region and that a strain predominant in Bangkok is driving the increase in HIV in the Asia Pacific area.

Health as a human right was also touched on with Chris telling us that a low proportion of PWID are receiving ARV. Despite the efficacy of HIV PrEP being proved in 2011, the roll out of this HIV prevention strategy was yet to happen.

Chris discussed how dealing with stigma and discrimination issues is a valubale tool in the fight against HIV. He highlighted how the 'war on drugs' drives PWID underground and this in turn fuels HIV/HCV rates. He drew attention to the appalling treatment of MSM as well as PWID In countries such as Indonesia and the Phillipines. In a bid to end discrimination, UNAIDS has appointed a 'SOGI' (Sexual Orientation and Gender Identity) Officer to monitor rights abuses of the LGTBIQ community. Whether this officer has any powers or impact remains to be seen.

Chris' take home message about fighting HIV in the Asia Pacific region was clear: 'MORE NEEDS TO HAPPEN IN THIS REGION'.