Mekala Srirajalingam

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.

Mekala Srirajalingam

Mekala Srirajalingam

Mekala Srirajalingam is a consultant physician with dual specialist qualifications in Sexual Health Medicine (AChSHM) and Public health medicine (FAFPHM) and works at The Ipswich Sexual Health Service and Metro North Public Health Unit [part-time relieving].  Mekala also and holds the academic title of Senior Lecturer with The University of QLD

Thursday 21.07.2016 -Hormonal Contraception and HIV: A Review of the Science and Research, and their implications for Research, Programme and Policy.

Some studies suggest an association between specific hormonal contraception methods and HIV acquisition.   DMPA has been mostly implicated.  Information has come from observational studies alone. 

Chelsea Polis, US, presented an updated systematic review,updating their previous 2014 review, Ten new and 21 studies from past review were included in the analysis. 

 

Patches, rings, Hormonal IUDs:  no data

Implants:  very limited data on LNG implants, does not suggest increased risk.

OCPs [Oral contraceptive pills]:  substantial amount of data, does not suggest increased risk.

DMPA [depot medroxyprogesterone acetate ]:  substantial amount of data, newer data are increasingly concerning and converging around 1.2 -1.6.  

NET-EN [norethisterone enanthate (NET-EN)  ]:  limited data; less concerning than 2014 review, still worthy of investigation.  

Questions were raised regarding the reliability of the results considering the nature of the studies, none being RCTs in particular relating selection bias. ie. Women at higher risk for HIV choosing DMPA.  

Another delegate stated that pregnancy per se increases risk of HIV acquisition by around two fold and there is a need for reliable contraception; hence findings of any small increases in risk of HIV acquisition with DMPA should be considered in context.

Jared Baeten, US,  Update on ECHO Multi Centre,  Open Label, Randomised trial on HIV acquisition among users of different hormonal contraception methods [DMPA, LNG implant, Cu IUCD].

 

N=7800 f/u , 12 sites in Kenya, South Africa (9), Swaziland and Zambia.   18 mths per women. Quarterly follow up with usual standard of care.

Started in 2015 and will go on for ~36 mths.

This is a very important study.

 

Janet Hapgood, SA, Biological/immunological mechanisms for an association between HC and HIV

Very interesting presentation with regard to progestogens: different doses, methods of delivery, duration, inter-individual variation,  differ in their off-target effects via different steroid receptors which predicts different side effects.   DMPA has activity like cortisol. 

Conclusion: Collectively, clinical, animal, and ex vivo studies are broadly consistent and show that DMPA increases permeability of the female genital tract and compromises select FGT and systemic immune responses.  This most likely leads to increases in HIV acquisition via multiple mechanisms more so in some individuals than others. 

 

Andy Gray, South Africa,  presented on Interactions between HC methods and ART- updated systematic review.  This review was to update the evidence on which the WHO guidance and local policy is bases.

ART and HC effectiveness

·         Efavirenz – most clinically significant interactions were with Efavirenz. 

Implant users:  pregnancy rates from 5-15 per 100 w-y.   (c.f 0-2 per 100 w-y)

Combined oral contraceptive pill:  13-15 per 100 w-y. 

DMPA: not impactecd.

·         Nevirapine – No significant impact.

 

 

HC and ART effectivenessNo significant effect noted.

 

DMPA and PrEP – no significant effect. 

Conclusions include:

·         Current published data do not support limiting access to any HC.

·         Full range of HC options should be made available

·         More well designed studies are required to study drug interactions

 

 

Tagged in: AIDS2016

The Lancet Special Theme Issue:  HIV, Viral Hepatitis, and TB among Prisoners

Lancet July 2016 issue has been dedicated to prisoner health, with more information online available from the Lancet website.  It is a sincere hope that this issue and discussions raised at this conference will influence the care of prisoners around the globe.

 

In this sessions the lead authors presented: a global review of the burden of HIV, viral hepatitis and TB among prisoners; clinical care among incarcerated women and men; best practice for prevention in prisons and jail; human rights and right to health access; and two region-specific presentations- on prisoners in Eastern Europe and Central Asia and Sub Saharan Africa.  Kate Dolan from UNSW presented on the Global epidemiology of HIV, HCV and TB in prisoners.

 

Annually 30 million people are passing through some form of detention.  These people are at high risk of acquiring and transmitting infections due to risk that are in play before and after incarceration.

Developed nations are not leading by example with US having the highest incarceration rates in the world, with blacks over represented  in the prisons.   Only eight countries have needle and syringe exchange programmes in prison.  The focus of incarceration should be rehabilitation. 

There is a moral and legal imperative to provide appropriate care to prisoners.  Only by including them and other marginalised populations in the global HIV/AIDS response, will the fast-tract to accelerate the fight against HIV and to end the AIDS epidemic by 20130 become a reality.

Recommendations:

  •  Reduce incarceration for key populations, especially people who inject drugs
  • Introduce and scale-up HIV prevention with Opioid Agonist Therapy, Needle Syringe programmes and Anti Retroviral therapy, including effective transitional programs post-release
  • Improve testing and treatment strategies (continuum of care) for HIV, HCV and TB.
  • Eliminate the gap between prison and community treatment and prevention services, including structural impediments for service delivery and continuity.
  • Integrate services given the high rate of medical and psychiatric co-morbidity.

The Standard Minimum Rules for the Treatment of Prisoners were first adopted in 1957, and in 2015 were revised and adopted as the Nelson Mandela Rules with eight substantive areas revised. By the UN General Assembly in December 2015.   

UN Standards on Treatments of Prisoners -- Mandela Rules (2015)

·         Prisoners must be managed in a manner to respect and protect the human rights and dignity of prisoners. 

·         Prison should be viewed as a place for preparation for reintegration of prisoners and society - minimise differences with outside world. 

Adequate space, food, sanitation.

No discrimination.

Health care to meet prisoner's needs throughout detention and linkage to public health.

Monitoring and accountability.

 

“It is said that no one truly knows a nation until one has been inside it jails.  A nation should not be judged by how it treats it highest citizens, but its lowest ones.”…………Nelson Mandela

Tagged in: AIDS2016