Priya Loomba

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.

Priya Loomba

Priya Loomba

Dr Priya is a GP Registrar and s100 prescriber. Interests include sexual health, HIV, hepatitis and family planning medicine. Priya works at Balmain GPC and is progressing through her GP training having completed terms at Liverpool Hospital, The Royal Hospital for Women, and two years at Sydney Sexual Health Centre. Her focus is to provide on-going community care for patients with varying sexual and complex care needs, both in urban and remote settings.

STI screening in the context of PrEP

Wednesday 23rd Feb Session TD-12

It’s Complicated: Renal Function and STIs in PrEP Users.

STI Data From Community-Based PrEP: Implementation Suggest Changes to CDC Guidelines.

Presenter: Sarit A Golub (NY, USA). Oral abstract an Poster.

 

Main findings of a review of STI screening in the context of PrEP;

Current CDC guidelines recommend screening at 6/12 intervals or earlier only if symptomatic.

They decided to screen all PrEP attendees routinely regardless of symptoms at 3/12 intervals.

They found that 77% of STIs would have been missed if they weren’t screened at the 3/12 routinely because of reporting as asymptomatic.

STIs screened were; Gc, CT, RPR in urethral and rectal samples. Pharyngeal testing was also done but not included in this study. The majority of PrEP attendees were between 22-40yrs of age.

Test of cure was only conducted on those that were documented as not having received first line therapy at the time of initial diagnosis. Current treatment for rectal CT was 1g Azithromycin, but 7 days Doxycycline was offered if TOC was +ve.

The researchers have also proposed a theory for why there was a spike in STI detection at 6/12. Anecdotal only, but PrEP attendees reported increased sexual risk activities after the 3 month initial HIV screen had come back negative, so they could actually believe that PrEP was effective for them.

Overall they are recommending that in light of many new PrEP guidelines and protocols being developed that STI screening of MSM on PrEP should be 3/12 regardless of symptoms.

 

These recommendations are in fact consistent with our current STIGMA guidelines for MSM screening that suggest testing up to 4 times per year.

http://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf

Something additional to consider is that should and if PrEP be prescribed by any clinician, without S100 authority, then there may be a need for some re-education into promoting sexual health screening especially in the community general practice setting. 

Tagged in: CROI2016 PREP STI
With or without ART, CVD risk matters

Session 0-4 Complications from Head to Toe

Early Antiretroviral Therapy Does Not Improve Vascular Function: A START Substudy. Abstract 41

Presenter: Jason V. Baker (Minneapolis, MN, USA)

They utilised diastolic aspect of cardiac BP waveforms to assess elasticity and vessel function.

Participants were generally a young cohort in their 30s and with CD4 counts >600

CVD (Cardio-vascualr disease) risk was low for the study cohort that was on ARVs, but was slightly increased for those participants that were in the ARV deferred group.

For HIV +ve patients consistent changes were noted across all age groups. 

It was notable that both HIV +ve groups (Those on ARVs and those in deferred arm) had lower elasticity baseline in comparison to the general (non-HIV) population, from CARDIA.

No specific difference in elasticity between ARV and deferred HIV +ve groups.

Overall the findings of the substudy did not show any benefit on vascular elasticity from commencing ART early. It did however highlight how vascularity is compromised within HIV +ve patients and hence for all our HIV +ve patients regardless of age we should take assessment of their CVD risk seriously and conduct this routinely, even for the young of age and those with suppressed viral loads and good CD4 counts. 

Tagged in: CROI2016

A brief blog reviewing the Bernard Fields Lecture. Monday 22nd Feb.

T Cells Control of HIV: Implications for Vaccines and Cure.

Speaker: Dr Bruce D Walker (Harvard, MA, USA)

In summary CD8 T cell immunity is still undergoing vital research in assessing how it impacts on overall immunity specifically relating to HIV. Can it help us in a cure or vaccine development? 

Known that CD8 T Cells can kill infected cells before progeny virions are produced. Yang 1997 showed that In vitro CD8 cells can kill HIV infected cells.

In order to assess T Cell response in initial pre peak viremia infection they are studying HIV infected babies in Durban, South Africa. FRESH program was implemented. It was noted within these patients that the rate of increase in viral load was similar across all new infection babies, but the actual peak viral load number and time to reach that in an individual varied. http://ragoninstitute.org/international/fresh/

 From current findings they have found that CD8 cells increase their activity within the human body just after initial exposure to HIV, a substance known as PD-1 is expressed and the more of this that is expressed over time there appears to be some correlation with the immune system getting turned down in regards to response. This was apparently similar to what has been noticed with cancer modulating cells and immune response impact.

They have been able to show that HIV some how activates CD8 activity –they hypothesize that perhaps active CD8 T cells are HIV specific. It was noted that an increased level of CD8 cell activated initial stages of infection was linked with a lower viral load set point.

Two other markers noted to be of relevant were, BCL-2 and perforin. As BCL-2 was activated CD8 cells underwent increased apoptosis, and similarly as there was a loss in perforin there was a progressive decline in CD8 functionality.

Overall early treatment does impact the overall quality of the immune response. To further hypothesis but if CD8 cell functions were maintained by commencing treatment in the pre-viremia stages of infection exposure could this help in the development of a cure and it’s effectiveness.

At the conclusion of the talk, despite being moderately confused with the biochem aspects, I got the impression that for now in order to help the development of future effectiveness of a potential cure we need to maintain baseline immunity of newly diagnosed HIV positive patients as much as possible, and prevent the exhaustion or destruction of CD8 cells after peak viremia.

I’m not sure if I would use this particular pitch to promote early commencement of ARVs in patients or for increased testing programs to detect earlier, but it’s food for thought as to why there is a possible other reason to suppress viral loads as early as possible.

 

Panel Discussion on Stigma, Trauma and Stress: Considerations for HIV Research and Programs

Monday 22nd Feb

Session MD – Panel Discussion on Stigma, Trauma and Stress: Considerations for HIV Research and Programs.

Moderator: Morenike Ukpong-Folayan (Nigeria)

Diversity in panelists: Laurel Sprague, Sethembiso Mthembu and Keith Green.

 

Speaker 1

Laurel Sprague: Limits and Complexity Research on Stigma and HIV. (Milford, PA, USA)

Complex topic for discussion and opening panelist Laurel Sprague opened with Stigma, fear, and anxiety around disease is just as important as the focus on reaching undetectable viral loads.

She continued to highlight that HIV positive people surveyed actually want not disclosing ones HIV status to be decriminalised, and it is the ongoing impact of the possibility for incarceration that is continuing HIV stigma within the US.

Discussion around the Stigma Index Questionnaire within the US and globally. http://www.stigmaindex.org

 

Speaker 2

Sethembiso Mthembu: Women’s Rights and Decision Making in Hormonal Contraception. (Durban, South Africa)

Presented on how there are overriding political issues that continue to impact on the provision of care for women, different contraception is offered in northern regions to southern regions, and based on religion and race.

Increasing awareness into the effects of hormonal contraception – in particular depo provera injection has on vaginal pH levels and thus is actually increasing the risk of HIV transmission for African women, as well as an increased link with higher rates of cervical cancer.

ECHO Study is currently looking at the direct links between administration of hormonal contraception and increased rates of HIV.

http://echo-consortium.com

Current government programs push hormonal contraception onto African women with little education or communication of possible side effects, in HIV positive females, provision of ARVs is withheld until the person can prove they have had their depo provera injection

Ongoing provisions of care complications are highlighted with African women being provided with ‘contraception only’ clinics, which will not and do not address any other complex care needs of women’s health.

We can all argue how effect depo provera is as a form of contraception that is discreet, effective and economically accessible around the world. The point raised by Sethembiso is that we need to consider and understand the impact however such hormonal contraception is being pushed in Africa not as an option but with forced prescription and the impact in relation to HIV risk.

 

Speaker 3

Keith Green: Engaging Young Men of Color in Community HIV Prevention Studies. (Chicago, USA)

Emphasis on multi-disciplinary approach and peer lead and consumer inclusion into study development and implantation.

He notes a major aspect of barriers in engaging youth consumers and participants into new studies and trials is not due to just their own stigma concerns but rather also the fact that youth inherently rebels and does not like to follow set orders or rules, and is just part of their nature as humans.

Keith also highlighted that we should not be so quick at labelling and using terms as MSM to communicate with young people, in todays day and age the better options is to ask the person how they wish the be identified and then use that term.

He has raised some interesting points, but also it does seem that it is increasingly difficult to allow interactions across all politically correct and non judgmental levels without making the research less valid, or repeatable in other settings, if allowing too many broad topics, and individual approaches helps gain numbers of consumers to participate will it then also indirectly make the research less scientifically valid?

The use of facebook and twitter proved valuable to their team in engaging and maintaining participation from youth consumers. The importance of privacy and sensitivity was highlighted but most participants were very happy to communicate via social media rather than phones. In considering the youth of today, mobile numbers change frequently, however very few will ever change their facebook or their email. Putting privacy and internet safety of information aside and assuming all was protected, one would think that this approach could not only benefit in youth interactions but also for all consumer/ client groups that are often lost to follow-up, low retention of care populations and indigenous and/or remote populations within geographically diverse Australia.

Keith repeatedly emphasis the importance of health provision to always remain culturally competent and relevant. This is of course a huge challenge in any community and country around the world especially as technology and communication avenues evolve so rapidly.

 

Open Q&A - Discussion:

The open discussion highlighted some global issues on the topic and some interesting specific examples were given. To summarize the main points of the discussion;

-       HIV prevention and control act implemented in Uganda has actually increased stigma, trauma and stress with the implantation of heavy fines on HIV positive people.

-       Is incarceration as punishment actually discrimination? In South Africa women are targeting for testing drives esp in antenatal screening – however if testing positive are indirectly persecuted, hence promoting fear towards testing.

-       Is the threat of incarceration a why in which governments globally can still impose authority.

-       Fears for women was further highlighted by the following scenario: If a man rapes a women in South Africa he is charged with rape and undergoes mandatory HIV testing, if positive he is then also charged with infecting people. On the flip side, the women raped is also tested, and if she is found to be the source, then she goes from being the rape victim to potentially facing a charge for HIV transmission to the rapist!

-       Do HIV, MSM and Sex worker clinics promote health care and reduce stigma or do they promote isolation and less integration and public understanding by segregation.

-       How can we reduced the distrust between consumer populations and research communities. Is it by educating, training and giving voice in positions to consumer/ peers. Would a society then specifically place aside allocated funding and positions for consumers/ peers to enter the industry and become researchers. In the Australian context how would this be rolled out? Similar to indigenous program models and would this encounter any population bias or speculation, helping reduce stigma or increasing it?

 

Session OS  - Opening Session - Fighting AIDS with Style 

On an additional note the final speaker of the day at the opening session was a special event guest, designer Kenneth Cole, now chairman of amfAR. He has dedicated his social and influential career in the fashion industry since 1985 to helping reduce stigma by being an individual public voice. From his efforts to not live in the dark or silence and instead pushing controversial AIDs and HIV issues into the public light.  https://www.kennethcole.com/lgfg-making-aids-history.html

It is something about the concept of stigma, trauma and stress in relation to HIV in all aspects including research barriers that should be challenged by more people speaking out and making it an acceptable public topic for discussion. When society is forced to fell comfortable about what is actually going on around it and within it, it is then that ignorance and bigotry can be overcome and help reduce stigma and hence promote public health.

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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