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.

Maung Maung Sein

Maung Maung Sein

Currently in the Rural GP Program of Tasmania and member of RACGP. Interested in Sexual and reproductive health, including HIV and Viral Hepatitis. Recently, completed both HIV and Hep B Prescriber Program and very keen to practice and help in the rural community of North West Tasmania.

The talk was presented by Dr Jeffrey D Klausner, Professor of Medicine, Department of Infectious Disease, University of California, Los Angeles, USA

Outline

·         What is self – testing?

·         How is self – testing Adopted?

·         What is the fidelity of self – testing?

·         Where can self – testing can be disseminated?

Self – Testing for HIV Infection

Only US FDA approved in Home HIV testing kit which used similar technique of Western Blot

Used by over a million consumers and same device used by health care professionals recently

The technique is simple oral swabs, no blood, and results will be in 20 minutes

24 bilingual customer phone support and details product website offering information, referrals to care, product usage instructions and more

Higher consumer satisfaction

Self – testing adoption

Influenced by user’s perception of costs, benefits, personal need and convenience.

Users greatly prefer painless oral testing over finger stick or venepuncture

Additional benefits include increased confidentially, privacy and reduced social stigmatization

Self – testing Fidelity

Original studies by manufacturer < 2 % failure

-          Limited by use of select population (MSM)

-          US adult vs trained providers ( Sensitivity 92.9% vs 99.3 % )

Singapore, error rate 0.6 %

Atlanta, 9 % error rate

China (non – Oraquick) 10 % difficulty swabbing, 17.5 % difficulty reading results

In NYC young MSM and transgender women reported concerns of anxiety, test correct use and instructions

Self – testing Dissemination – Los Angeles

-          Vending machines

-          Vouchers

-          US Priority mail

-          Online

Vending Machines in sex clubs which are located at private areas with self – contained unit that can be monitored remotely as well as posted instruction how to use the kit

Initial Concerns for Vending Machines

·         Cost of HIV home test kits

·         Emptying the vending machine

·         Conflict with existing testing programs

·         Home test kit window period

·         Result anxiety

Results summary over 7 weeks, in 2014

-          1176 hours and 312 tests for Vending machines versus 64 hours with 58 tests for traditional testers with clinicians

Providing Vouchers for the free test kit that can available at Pharmacy is also very positive outcome 

Social Medical Promotion commenced since 2014 through Periodic advertisements

In General, among three choices; vouchers, vending machine, priority mail to home 

Approximately 2/3 used Mail services and 1/3 of other consumers accessed through free vouchers, 67 % and 30 % respectively. Only 3 % used vending machine to get the self – testing kit  

Linkage to care for community

HIV Self- test added as a reported element in HIV Surveillance and also follow up management goes through by receiving the positive test kit photos taken by consumers

STD Self – Testing

·         Self -collection urine send via mail for STD testing

·         Self – referral syphilis lab testing

·         Commercial home – based collection and shipping

·         True home – based collection and self – testing.. .. not yet but coming soon.

Among all, using Mail for screening is the most cost effective method

Summary

·         HIV self – testing is desirable, safe and effective – WHO recommended

·         Need more evidence on outcomes, impact and cost effectiveness

·         STD home – specimen collection and self – referral options

·         True STD home – based self – testing …. Coming soon and waiting approval from FDA

Presented by Dr Ayden Scheim, Division of Global Public Health, University of California, San Diego, USA 

Overview

1.       Trans populations are incredibly diverse

2.       Trans women disproportionately impacted by HIV globally

3.       A “global” picture obscures context & knowledge gaps

4.       Trans people face multi-level HIV /STI vulnerabilities and protective factors

5.       We must make trans people visible in HIV & sexual health

6.       A trans sexual health agenda is needed

Trans populations are diverse

Trans and gender diverse identities

-          Trans women/ trans feminine & trans men / trans masculine

-          Non- binary

-          Two Spirit

-          Sistergirl/ Brotherboy

0.6 % of US adults (~ 1 in 160) are trans gender compared 1.2 % of NZ high school students

Gender Identity

Non Binary people counted 35 %, while 33 % of Transgender women and 29 % of Transgender men with the least proportion is Crossdressers, only 3 %

Medical Transition (hormones and / or surgeries)

Almost a quarter already had completed transition and next quarter is still in process. Other half include; Planning but not begun, not planning to and not sure group as well as concept does not apply group

Ø  Trans women face a disproportionate HIV burden globally

-          Based on paper from Baral et al, Lancet Infectious Disease 2013, the pool HIV prevalence was 19.1 % in 11066 transgender women worldwide.

Trans men

Qualitative data is very limited and Lab confirmed HIV + varies from 0 - 4 % while self reported presented from 0 – 10 %

Choosing the right denominator

-          2/3 of trans men identify as gay, bi, queer but only 1/3 of those had sex with cis men

Trans MSM seem a lot like other MSM; however countervailing risk & protective factors shown as below are unavoidable

-          Sexual abuse, stimulant use, depression, syndemics predict risk behaviour

-          But are distinct in consequential ways

-          Exclusion from gay communities

-          Less anal intercourse

-          Changes to genital mucosa

Therefore, Trans people are not MSM….. except for when they are

-          Include trans MSM alongside other MSM

-          Who will be accountable to trans women ?

Summary

A trans sexual health agenda based in access to gender affirming care including hormones and surgery, reproductive care, HIV / STI prevention, screening and treatment in a context of gender recognition and rights protection

Background

·         Gay and bisexual men’s sexual practices have evolved throughout the HIV Epidemic

·         Protective strategies (e.g. condoms) have often been community led/ generated

·         Every technological innovation in HIV testing, treatment and prevention has prompted shifts in practice

·         Australian GBM’s practices have been monitored by the Gay Community Periodic Surveys since 1996

·         What follows is a review of trends in selected practices since 2000

( national;unadjusted;7 states / territories, > 6000 participants per year; only NSW & VIC in 2017 )

Findings

Overall, partner numbers have declined over time, except in 2016 – 2017

Majority of men in relationship have condomless sex with their regular partners. This became more common after 2010 which is around 60 % in 2017 

Regarding HIV status, 30- 40 % of HIV Negative partners with similar status while both partners positive observed just under 10 %

HIV negative relationship more common after 2010

Condom use was primary prevention strategy, with casual partners and Anal sex has become gradually more common with casual partners.

 

 

Risk reducing strategies frequently used during condomless sex with casual partners

-          HIV positive men who had CAIC  ( Condomless Anal Intercourse ); 2011 – 2017 counted Undectable viral load 80 % whose partners are on PrEP around 40 %

-          HIV Negative men who had CAIC represented around 50 % whose partners on PrEP approx. 40 %

 

Summary

·         Up until recently, Gay / Bi men were reporting fewer male sex partners over time

·         Since 2000, condomless sex has become more common

-          First emphasising serosorting ( matching HIV status )

-          Now harnessing PrEP and treatment as prevention

·         In the last 5 years,

-          HIV positive men have switched from serosorting to undetectable viral load as their primary strategy during condomless sex with casual partners

-          HIV negative men have rapidly embraced PrEP and many continue to serosort

·         The vast majority of GBM continue to minimise HIV transmission risk, using an increased range of strategies

 

The Talk was presented by Mr Joel Murray, Senior Officer Policy and Research from Living Positive Victoria 

Reference from Reform of the Sex Work Act 1994 ( VIC ); Policy Statement

Introduction 

Living Positive Victoria, The Victorian AIDS Council, Scarlet Alliance: Australian Sex Workers Association and Vixen Collective: Victoria's Peer - only Sex Worker organisation, are supportive of the full decriminalisation of sex work in Victoria.

The Position statement deals with the narrower issue of sex workers living with HIV, but it should be seen as part of a broader call for full decriminalisation of sex work. Law regarding commercialised Sex should mirror those of other consensual sexual activity. This statement summarises the case for reform of the Sex Work Act 1994 ( VIC )

Background

Sex work in Victoria has been regulated via a licensing system since 1986. A licensed system allows for the establishment of Brothels and escort agencies. Similarly sex workers are required to be registered in order to work legally in brothels and escort agencies. It is currently illegal for as person living with HIV ( PLHIV )to undertake sex work. 

The knowledge of HIV in 1986 was limited - WHO advised governments around the world that Sex workers were an at- risk population. Therefore, to not allow PLHIV to engage in sex work was seen at time to be in the interest of Public health. 

However, in 1994 when the current statute was enacted, increased knowledge of HIV and treatment, the advancement of human rights of PLHIV and the sex industry's considerable efforts in health promotion, demonstrated that provisions within the statute that disallowed PLHIV from undertaking sex work were not justified on Public health grounds.

Issues

Public Health and Human Rights 

The prohibition on HIV positive sex workers does nothing to protect public health, but rather forces HIV positive sex workers to work illegally, potentially harming HIV response by driving HIV underground. 

The Equal Opportunity Act 2010 sets out attributes on the basics of which discrimination is unlawful according to Victorian law.

Barriers to accessing health and HIV specific services

Criminalisaiton of sex workers living with HIV establishes a barrier to access services, treatment, care and support. ALL PLHIV should be able to access education and effective antiretroviral treatment to further reduce risk of HIV transmission. 

Stigma and discrimination 

Sex workers living with HIV face the potential for multiple levels of stigma and discrimination depending on their personal circumstances and how they wish to identify. To identify as both living with HIV and being a sex worker is to face at least twice the level of discrimination. 

Sex work and HIV in Australia 

In Australia, significant efforts have been undertaken to ensure the widespread adoption of safer sex practices in the sex industry. This has resulted in lower rates of STIs among sex workers compared to general population. In addition, there have been no documented cases of HIV transmission from a sex worker to a client in Australia. 

Inconsistent laws between Australian jurisdictions relating to sex work by PLHIV, may cause a person to unintentionally break the law simply by going about their work in a state or territory has different laws to their place of residence.

Policy Context

This position is supported by a number of Australian and international policy contexts, including but not limited to

  • Victorian HIV Strategy 2017 - 2020
  • Seventh National HIV Strategy 2014 - 2017
  • AIDS 2014 Melbourne Declaration; nobody left behind
  • UNAIDS Guidance Note on HIV and Sex Work
  • UNAIDS 2016 - 2021 Strategy 
  • UN General Assembly Political Declaration on HIV and AIDS 2001,2006,2011 and
  • The Ottawa Charter for Health Promotion

The Talk was by Rimke Bijker who is a PhD Student from The Kirby Institute. 

As aging population with HIV positive in Asian countries, risk of increasing trend of Cardiovascular Disease is unavoidable. Overtime, about 60 % of patients (HIV Positive) will be aged over 40 years in 2025.

Risk of  Cardiovascular Disease (CVD)comprises traditional risk factors as well as specific factors

- Traditional risk factors comprises dyslipidaemia, diabetes status, hypertension and also smoking

Specific factor such as high Viral Load count, Low CD 4 count 

There is an ongoing research Over 10 - year period at Asian region, which included 20 clinical sites, 12 countries and some part of South East Asia 

The cohort data base was used from TAHOD ( Treat Asia HIV Observational Database ) was established in September 2003

 

This based on Gender, Age, ART regimen, status of Diabetes Mellitus 

Assumptions

- Patient remains on current anti retro viral therapy 

- Stopped Abacavir ( ABC ) < 6 months ago 

- No Family history of  CVD data, based on prevelance of the same population

Clinical Data

Total number of study - 3406, comprises ;Male 69 % and Female 32 %, > 50 age  29 %

Hetero 68 % Homo 29 %

Projections

– increasing trend doubled of risk of Diabetes in 2026 compared with 2017, ( almost 1500 events in 2026 )

- Global data for burden – 900 events, although throughtout the period the same for 2026

 

Subgroups of outcome 

-          Male > female

-          Age > 50 higher than younger

-          Income does not change the outcome 

-          DM > than no DM

-          Protease Inhibitors  > no Protease Inhibitor Regime 

Limitations of Study

-Critique on risk scores

-Generalisablity

-Risk score Based on mostly European population 

Take Home Message 

There will be doubling of CVD events in a decade time. Therefore, Primary physicians / health care professionals need screening for those population

 Age as Older patients, having Diabetes and also taking PI Regimen are high risk of having CVD events 

There is no conflict of interest for this study 

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