HIV co-morbidities – are we measuring and responding them appropriately?

KEY POINTS

People living with HIV

-       Have increased frailty compared with the general population as they age calling for MDT/ holistic approach as a response [Jenifer Hoy]

-       More at risk of polypharmacy (>5 meds). Polypharmacy can lead to non-adherence, morbidly, Side effects, and interactions. The PAART study showed that >75% took >1 concomitant medication. The most commonly prescribed concomitant medications included lipid lowering medications, antidepressant, antiviral, PPI, anticoagulant, PDE5i, anti-diabetogenic and anticonvulsant. Many of these have serious interactions with ART. >700 interactions were found and 18.9% were on a CI regimen. Showing the importance of coordinated care, rationalising medications and regular good drug histories to prevent interactions.. [Krista Siefried]

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-       Increased risk of renal disease (historically due to HIV now shifting to ART and advancing age). Renal disease is associated with worse patient outcome and people with risk factors/ renal disease benefit from early intervention, screening and management. There are no guidelines in Australia that look at  monitoring for renal disease in PLHIV. However, there are international guidelines (EACS) that propose U&E and protein creatinine ratio (PCR) to stratify PLHIV into risk categories and then refer to specialist as appropriate. In a retrospective case review n=229 mainly male 30-39 with Low prevalence of known renal disease. Only 34% had PCR despite high prevalence of renal risk factors including smoking, HTN, HCV and low CD4/ high VL. Lack of simple urine dip signified a missed opportunity to pick up early disease/ proteinuria. Screening for renal disease fell below recommendations and should be considered in PLHIV [Tahiya Amin]

New approaches to HIV testing

Delayed HIV testing among men who have sex with men in Australia has improved but remains an issue – Huachun Zou

KEY POINTS

·      Delayed testing (testing less than annually) in MSM has improved but there is still some way to go

·      In Australia it is predicted that there are approximately 12-33% of people living with HIV who are undiagnosed

·      2/3 MSM consistently report testing but less than 40% return to be retested within 1yr

·      If all MSM were tested as recommended (every 3-6 months), modelling predicts there would be a 14% decrease in new HIV diagnosis

·      However, surveys have shown that only 1/3 are ‘very likely’ to increase testing levels. Many MSM don’t test annually and those at higher risk (5 partners in 3/12, >20 partners in 12/12, having had an STI in 2y) tend to be the most unwilling to increase testing.

·      ACCESS data from 2007-2014 from 24 sexual health clinics showed those more likely to test >p.a were under 25. Only 36% of high risk MSM tested annually and only 2% ATSI.

·      Amongst those at high risk delayed testing has improved from 75% to 69%, with delay in testing being more likely if ATSI, this was statistically significant.

·      In conclusion delayed testing is still common in high risk MSM especially if older or ATSI

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·      Strategies to improve testing further could include ?home based/ self test HIV testing, 3/12,  sms reminders (shown to work), computer alerts in GP practices and guidelines on testing (also shown to work).

Stigma and discrimination in Timor Leste - Ines Lopes, Executive director, Estrela+, Timor Leste.

KEY POINTS

·      Timor leste  a catholic, spiritual and ‘moral’ based society.   

·      631 cases of HIV. 231 on treatment (75 deaths) – considered low prevalence

·      ESTRELA+ Aims to allow people living with HIV to live with dignity/respect free from discrimination  through community based teaching in response to challenges faced due to conservative nature. HIV taboo, cannot mention sex, ‘moral’ attitude promoting immoral attitude to those living with HIV. This leads to people living with HIV not disclosing status to healthcare/ employer

·      ESTELA+ fund misinformation was widespread with media playing a significant a role in perpetuating this. It was found that Stigma could be extreme and revolved around HIV being seen as an ‘immoral’ or ‘bad’ disease. Some stigmatising behaviour included being called ‘dirty’/ shouted at/ violent threats/ forced to move/ rejected by family/ medicine thrown away by family/ prevented to visit healthcare/ baby removed by family.   

·      People living with HIV had concerns with regards to lack of confidentiality and differential treatment in health care. This meant people living with HIV were more likely to use free foreign clinic as they felt that they had better treatment and confidentiality was respected.

·      Change continues to take place through solidarity and support, lobby the government  with regards to labour rights. Community groups have worked with the church to promote tolerance and work  has been done at a community level to disseminate evidence based information and community training.

Perceived stigma is associated with non adherence to ART; a case study of a community- based sms reminders campaign - Limin Mao

KEY POINTS.

·      Trial of 6-week intervention of community driven sms reminder/ congratulatory sms to assist with ART adherence. It comprised three groups:  G1- 2 way sms 3/wk, G2 - 2 way sms 2/wk, G3 - 2 way sms 1/wk.

·      Valid responses – roughly split between 3 groups.

·      Characteristics included 85% Gay men, 25% outside metro area. Many lived alone without a partner pointing towards an otherwise isolated cohort.

·      34 with CD4 >500  - 11 increased, 2 decreased, 18 stayed same  (no statistical significance found)

·      During intervention (last week) 100% adherence. And adherence increased across all groups throughout the intervention.

·      Participants felt no stigma from non-adherence but  did report stigma related to: HIV status (31%), sexual orientation (27%), drug use (11%).

·      Participants reported majority of support came from  HIV clinician and HIV support groups.

·      Participants liked a community based reminder/ congratulatory message when adherent as it made them feel supported. They preferred receiving a message from the community as felt clinicians too busy and fear of letting clinician down if non-adherent. It was noted most already had strategy in place to assist adherence 

·      Sustained ART adherence is required, PLWH want community based support.

·      Future studies would need to look at if SMS reminders would be tolerate on a long term basis or more suited to initiation of therapy/ if having difficulty being adherent.

Development of a national monitoring system of stigma among people living with HIV in Australia - Carla Treloar

KEY POINTS.

·      The stigma indicators project  - was a brief indicator of stigma and measure of stigma over time including the mirror of stigma/ attitudes of healthcare professionals over last 12 months.

·      Results 200 ppl (>50/male/ gay /1% ATSI/ 5% CSW/35% PWID)

·      Almost all disclosed status to healthcare/family – fewer to employer/colleague.

·      Stigma most frequently experienced in media, amongst healthcare workers not paramedics and sexual partners.

·      Internalised stigma observed in 25%-50% - proving a significant experience for those surveyed.

·      1/3 – 3/4 reported they had been told by others that they had felt stigma from sexual partners.

·      In conclusion the preliminary data from ‘The stigma indicators project’ includes – stigma and discrimination most common sexual partners health worker and media.

·      Future work will covariate i.e. mental health and develop qualitative work with CSW and HBV and feed these results back to the national strategy.

ART use, stigma and disclosure changing attitudes among PLHIV 1997-2015 - Jennifer Power.

KEY POINTS.

·      FUTURE study

·      PLHIV Self reported physical health–good/excellent, general wellbeing good/excellent and this is consistent.

·      However, attitudes toward relationships and disclosure showed increase in concern over disclosing status, a consistently high preference for sero-sorting and a reduction in fear of virus transmission reduced,

·      FUTURE STUDY also revealed High rates of diagnosed mental illness (>50%), with 30% taking medication in last 6 months this mainly consisted of the 45-59 age group.  There was no sig difference between men and women.

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·      In conclusion, wellbeing study for PLHIV requires more than purely medical treatment and issues of stigma persist despite improved health/ viral suppression.

What PrEP means for safe sex in Sydney: evolving norms - Bridget Haire

KEY POINTS.

·      Bridget Haire discuses UNSW Qualitative study investigate how PrEP is affecting sex cultures amongst gay men on PrEP either privately sourced or on clinical trial, through interview and focus groups with gay men  and health providers.

·      Common themes discussed included: -

o   A new stigma evolving towards condom users that ppl not taking PrEP/ using only condoms are uninformed and condom-use lowers sexual capital.

o   Attitude towards STI’s includes a strong framework around testing and treating rather than condom use, accepting condoms not perfect and maintaining a strong community context.

(There remains a controversy amongst healthcare professionals as to whether there is a real increase in STI or just increased testing).

o   Attitude to Undetectable Viral Load  - polarised to ‘want to see it in writing’ to only asking if on medication or not.

o   Sex anxiety – PrEP has reduced sex related anxiety around HIV transmission.

·      In conclusion PrEP didn’t precipitate condom less sex as condom less sex predated PrEP but it does seem to be reinventing the idea of  ‘sexual citizenship’ (‘sexual citizenship’ first described by David T Evans in 1993 as the rights and responsibilities around ones sexual career). It seems a new stigma evolving with sexual rejection of condom users. This tension between PrEP and non-PrEP users needs to be addressed to develop the idea of that a combination of health promotions can reduce HIV.

·      The Implication is that health promotion needs to be embedded in the conversation that communities have in order to be relevant.  Future studies need to follow theses attitudes/ trends over time.

Day three Australian HIV/AIDs conference 2016  

Towards elimination:  parallels between HCV and HIV models of care – 

Joseph Doyle, specialist in infectious diseases and public health medicine.

KEY POINTS

•Australia has 230,000 cases of HCV, a relatively low prevalence. This consists mainly of PWID but also a      significant proportion who acquired HCV through sex, especially if HIV pos. 

•WHO 2020 targets aim for a 30% reduction in  new dx of HCV and a 10% reduction in deaths from HCV.

•To ensure success those at risk need access to frequent, regular testing to ensure early dx, with early dx leading to early connection to care. Australian guidelines recommend annual HCV testing for those at risk (or testing associated with a specific risk) and once ever testing for the rest of the population. 

•Testing programs need to be considered – as antibody/PCR testing take two visits, Genotype will hopefully be made redundant and liver disease test such as fibroscan – not required for people with APRI<. Rationalising testing reduces time required to treat. Rapid RNA and annual testing in PWID  - will help to meet WHO target. 

•Improvements in treatment have been due to highly effective treatment available on PBS (the near future will see a single pill regardless of genotype). Community prescribing (unique to Australia and supported by specialists), no disease stage restrictions and no need for fibroscan.

•Elimination is more likely if treatment is targeted to PWID/ MSM/ Overseas born (due to a small element of vertical transmission from more high prevalence countries). 

•Treatment of PWID has been shown to be effective/ safe/cost effective and can be given in conjunction with harm reduction strategies such as OST, NSP and peer support to increase the likely success of treatment and prevent reinfection.

•A scale up of treatment to 40/100 PWID p.a could halve HCV prevalence in 15 years and using injecting network data/bringing along injecting partners could reduce prevalence by 85% parallel to new dx HIV contact tracing .

•Other strategies include potential vaccines that even if only partially effective can still impact the epidemic in high prevalence area’s. 

•To achieve the mortality target those with advanced disease will need to be targeted, this can also be achieved by treating PWID due to new HCV cases prevented.

•In conclusion, to meet WHO targets of HCV elimination and reduced mortality testing and treatment will need to be targeted and include injecting networks. Rationalising tests and simplified effective treatment can go someway to achieving this goal. 

Day three of the Australasian Sexual Health Conference 2016

Professor Alan McKee sparked an interesting debate today around sex education with his lecture ‘What we can learn from Pornography?...

Healthy sexual development is part of becoming a well-adjusted adult, right? …but what is 'healthy sexual development'? Is there such a thing and if there is, can it be taught and incorporate the beautifully diverse nature of sexuality and sexual identity?

Studies have shown that sex education can’t be left to families alone and calls for health and education to collaborate to improve sex education and incorporate themes such as pleasure as well as the well-trodden path of sexual risk – could it be possible that we might learn something from pornography in this regard?

 In Angela Davies’s lecture yesterday we learned that young people are already watching porn for a more detailed and pleasurable form of sex education. However, the overall impact of pornography is unclear. Some young people describe this experience as positively impactful in terms of preventing risk behaviour and normalising taboos and others report resulting harmful attitudes. The impact of pornography on body image can be positive or negative and In some cases young people report pornography had no impact at all.

Is there a role for picture books detailing the story and diversity of vulvas? flaccid penises? erect penises? Menstrual fluid? Ejaculation? so that young people get a sense that there really is no such thing as normal or perfect. 

One attendee pointed out that showing young people pictures of genitals in the context of sex education could contradict child protection programs where young people are taught that their genitals are private,  however, the overriding feeling was – pictures of genitals for sex education could be ok if in an appropriate and safe context.

Personally, I think we have a bigger battle - forgetting porn for a second, young people are constantly bombarded with expectations of whats 'normal' outside of school, Advertising prohibits any hint or curve of a labia. Are we to implicated in these built up expectations? After all how diverse are the drawings of genitals in our anatomy/ biology text books?

Maybe we can take example from the Netherlands  where young people having a later sexual debut, the vast majority use contraception the first time they have sex and describe there first experience as 'being ready'. These healthy and positive sexual experiences follow a  ‘comprehensive' sex education that starts at 4 years old and educates parents too.  In fact, ‘sex education’ is termed ‘sexuality education’ and incorporates young peoples rights and responsibilities leaving them more assertive and better communicators compared to there counterparts around the world.  

Take home messages

• Young people are curious about sex (and always have been)
• Some young people (regardless of gender identity) watch pornography which more often than not has an impact, and that impact is not necessarily negative.
• Sex education is incredibly important, especially around issues of body image, but needs to go beyond sexual risk to meet young peoples needs.

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In the Gollow lecture Rebecca Guy discussed the important role of new technology for STI prevention including interventions such as: -

-CASI an electronic self-registration tool has proven acceptable reduced waiting times and improved data collection.

- ACCEPT showed the need for opportunistic Sexual health screens in primary care for young people due to high prevalence of CT and presenting complaint often not being sexual health related simple computer prompts increased testing by 30%

- SMS and postal test kits have been used to improve re-testing rates

Mark Hayter called for collaborations within sexual health with other specialities such as family planning and drug and alcohol services. Incorporation of family increased consult time but decreased unintended pregnancy, without increasing STI rates.  In addition inks with family planning could even go someway to dispel contraception myths held by Australian men as highlighted in Mary Stewarts lecture ‘contraception and the Australian male’.

Craig Rigney, CEO Kornar Winmil Yunti spoke about the KWY community based response to high rates of Aboriginal family violence and a lack of accessible culturally appropriate services. The Aboriginal family violence program maintained client safety through ‘women’s business’ and ‘men’s business’. Men’s business included a perpetrator program, which was aimed to unpack perpetrators own held trauma so that they can be accountable for their own violence.  Although initially many attendees were mandated from court self-referrals are on the increase. Rigney discussed that undoubtedly valuable outcomes are hard to evaluate.

In ‘rethinking testing and management of sexually transmissible infections’ Catriona Bradshaw drew attention to the lack of guidelines internationally for rectal MG with treatment shifting towards doxycycline. She called for a reduction in macrolide use and improved contact tracing and TOC rates.

Jane Tomnay analysed PDPT in the Australian context drawing attention to challenges in primary care such as who will pay for PDPT? And how do you write a script for the partner if the partner has never attended the practise.

PDPT was criticised in NT in 2012 when it coincided with child abuse allegations as a way that abuse could remain hidden – something to think about especially in relation to pick up rates of family violence/ domestic violence. 

Daniel Richardson proposes HCV testing should be considered in relation to sex in certain groups even if heterosexual (namely women) and in HIV negative MSM on PrEP – when asked about increased cost due to Australian labs only performing HCV RNA, Richardson suggested lobbying for HCV antigen tests he denied value of LFT’s as a screen, referring to the MSM in PROUD and EPIGAY whom contracted HCV through sex having had no change in transaminases.

In the sexuality lectures Hilary Caldwell Challenged gender based narratives about the Australian sex industry stating that its no longer sustainable to claim only men command and objectify bodies when buying sex or that that power dependent activity is inherently oppressive. She described how women buying sex (WBS) In Australia are more likely to do so from women than men and that these women were diverse with any ethnicity and any income. WBS stay for longer and buy sex less often prioritising safety and a sexpert. Angela Davies looked at the impact of pornography on young peoples sexual lives. There are concerns that porn can normalise risk behaviour promote harmful attitude. An Online survey of 15-29y revealed both male and females used porn. Porn was considered a more detailed sex resource compared to formal sex education where pleasure is the goal instead of risk. There were positive and negative impacts. Positives impact included – positive body image, sex positive, normalising taboos, ‘a safe space to sexplore’, in some males prevented other risk behaviour. Negative impact included  - negative body image, unrealistic expectations, and limited representation of sexuality, harmful attitude and behaviour. A significant portion reported no impact of porn. Do this group have protective factors preventing impact or are these most at risk who lack insight?

A huge thank you to Gracelyn Smallwood who gave an inspirational talk around the importance of involving appropriate people in a community to deliver culturally appropriate health promotion that engages communities as a whole.

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Day one of the Australasian Sexual Health Conference 2016 included presentations showing: advances in resistance testing and POCT for common STI’s, novel treatments of MG, possible reasons why Australia lags behind in LARC uptake, Australia-specific barriers to termination of pregnancy, as-well as issues such as the importance of a multi-layered representation of aboriginal men to aid with engagement around sexual health and how policy is protective of LGBTIQ young people in Australia.

Associate Professor Rebecca Guy discussed the challenges of STI testing amongst aboriginal communities in remote areas. She reported the average time to treatment being 21 days due to population mobility and distance to lab, with 1 in 5 not receiving treatment at all. 

In 2011 12 rural health services trained aboriginal nurses and health-workers to perform a POCT for CT/NG (‘Xpert’). This meant results could be given within 90 minutes. Treatment uptake increased to 96.2% (treatment uptake for the standard was 88.3%). The mean time to treatment reduced from 19 to 4 days with 80% being treated within 7 days (compared with 48.5% previously). Future studies will look at POCT for NG/CT cost effectiveness.

MG remains a concern with increasing resistance to azithromycin and moxifloxacin. Associate Professor Catriona Bradshaw explained how Pristinamycin could not be considered an alternative treatment in those where azithromycin had already failed due to a disappointing cure rate of only 75%. However, Pristinamycin may have a role in special circumstances such as pregnancy as it is safe with few side effects.

Dr Elina Trembizki proposed PCR resistance testing could individualise NG treatment by accurately predicting ciprofloxacin susceptibility through TCC/ TTC wild type detection. It possible NG resistance to ciprofloxacin may by over represented through traditional culture methods though this should only be interpreted in an Australia context.

In the reproductive health lectures Mary Stewert highlighted the need for contraception education in men as although survey through a dating website revealed high rates of contraception use there was a lack of awareness of LARC’s and many believed hormonal contraception especially the ECP to be harmful which could negatively influence female partner decision.

Australia still lags behind in LARC with only a 3.2% uptake compared with 13.9% worldwide. Dr Amy Moten dispelled myths about IUDs explaining that PID rates are now <1-2% regardless of age and only in first 20 days post insertion after which time risks go back to baseline. Studies have even shown that there is no benefit of removing IUD in PID unless there is no improvement in clinical status after 48-72hours. Therefore PID should not be a barrier to IUD’s. Gabrielle Lodge looked at GP perspectives towards IUD insertion revealing barriers to include cost to train, minimal Medicare rebate and de-skilling due to small patient load.

There was a call to make MTOP de-centralised and so more accessible and affordable.  As despite misoprostol being available on PBS professor Angela Taft found many women find cost a significant barrier. Spontaneous discussion highlighted women’s experiences can vary widely depending on the state. Lauren Coelli described a successful nurse-led approach used in Victoria and emphasised importance in training all members of the MDT including receptionist staff to de-stigmatise.

Other interesting lectures included Dr Deborah Bateson speaking about POP (75mcg desogesterol  - not available in Australia) as a treatment for migraine possibly due to anovulation. Associate professor David Templeton who presented the increased follow up of victims of sexual assault due to improved relationship between sexual assault and sexual health services, councillors calling individuals to make appointment, separate waiting room, councillor obtaining sexual history, and personal phone call with negative results. >10% of these patients had an STI showing the importance and benefit of proactive follow up.  Todd Fernando discussed how the media/ literature fuelled view of aboriginal men either being heterosexual or hyper-sexualised MSM needs to be remedied to aid engagement with sexual health services and Tiffany Jones talked about how policy made LGBTIQ young people feel safe. Lack of policy and poor education in schools around LGBTIQT leads to increased bullying, days off school, self harm and suicide whereas promoting activism can me protective.  

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