As the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) draws to a close I am reinvigorated and ready to implement changes in my own practice.

I was privileged to visit a local health facility and impressed by their ability to treat so many with limited resources. 

Despite the differences, there are many similarities in the emerging health needs of PLHIV and hepatitis C.

• Ageing populations calls for teams of primary healthcare workers.
• Hep C treatments are rapidly expanding across the Asia Pacific but barriers remain. Primary care seen as important in delivery of treatment in Australia.
• Hep C testing and treatment needed in communities with access to at risk populations.
• PrEP is emerging as the preventative health priority. Innovative approaches being used.
• Stigma and discrimination remains a barrier to access to care.
• Dual therapy ART looking more likely to be effective than not.
• Long acting ART development continues.
• Multiple new DAAs for hepatitis C on the horizon.

I have just finished an APACC promotional video and can recommend this conference to my Australian colleagues for next year.

Rajasthan, R, Malaysia ; HIV and ageing Study.

 

One of the emerging challenges is the ageing cohort of PLWHIV within Australia. Many of these individuals have complex co-morbidities requiring experienced clinicians and team based models of care.

Dutch data indicates that 2 of 3 HIV positive individuals within Holland will be aged >50 by 2025. Similar trends are expected in Australia.

There were many sessions and posters looking at co-morbidities and ageing.

Many abstracts highlighted the increased prevalence of CKD, atherosclerosis, peripheral neuropathy, neurocognitive decline, diabetes and osteoporosis in PLWHIV. Ruzicka D Japan, Rajasuriar R Malaysia, to name a few of the many presenters.

Reena Rajasuriar presented findings from the Malaysian HIV and ageing Study.

Attempts were made to adequately match study participants. The concept of functional age was a central tenant of the design. Prior studies were highlighted for lack of adequate controls and use of subjective, poorly validated measuring tools. Dr Rajasuriar commented that single entities are often used to measure the ageing syndrome.

The Malaysian study focused on the multi factorial nature of ageing. The use of comprehensive geriatric assessments were utilised to reduce subjectivity bias.

All 10 markers of ageing were increased in the HIV positive arm compared to matched HIV negative participants.

• 2.5 times reduction in QOL indicators.
• 4 fold increase in mortality
• 5 fold greater utilisation of health services.
• Significantly more sarcopenia and functional disability.

New models of care were called for throughout the Asia Pacific region. In particular multidisciplinary teams, including but not limited to, social workers, dietitians, psychologists, nurses, GPs, physiotherapists, podiatrist and exercise physiologists.

Comprehensive geriatric assessments were heralded as ideal.

Much panel discussion was generated through audience participation

• Is this a realistic concept?
• Is the process clinician driven or patient driven?
• What management strategies are cost effective?
• How do we manage the increasing burden of subcortical neurodegeneration?

This session was very informative generating much discussion amongst my Australian colleagues.

As demand for complex services increase service innovation will be required.

Australia is proposing a new patient centric and patient driven model of care. Health care homes as primary care coordinators are also a central  theme. This model is well suited to providing innovative care to the ageing population of PLWHIV.

Management of traditional lifestyle risk factors remains central to managing cognitive decline.

Focusing on functional age is increasingly seen as a more useful measure of healthcare needs rather than numbers of co-morbid conditions. 

 

 

 

 

     

Doyle,J (session presentation) ; coEC Study

Lu,Y (2 poster presentations) ; ASTRAL-5 Study

This presentation by J Doyle from the Burnet Institute highlighted the findings from the first year of the co-EC study in Melbourne. Modelling presented by Scott, et al at EASL 2017, proposes that treatment of 515 co-infected individuals in Victoria will reduce the prevalence of hepatitis C within the GBM community by 80%.

In the first year clinical data was collected on 160 chronic HIV/HepC co-infected individuals on ART. This included biochemical, haematological and fibrosis data. Primary care clinicians assessed this data and individuals either:

• received immediate DAA therapy (40%)
• received DAA therapy after specialist advice (31%)
• were referred for specialist care (19%)

Referrals were predominantly required for known cirrhosis, APRI score >1, malignancy, renal/cardiac disease or fibroscan >12.5Kp.

This study highlighted the capacity for the majority of non-cirrhotic HIV/Hepatitis C individuals to be effectively managed by a primary care clinical team. This model of care fits comfortably with Australia's move toward patient centred, community based care within health care homes. 

ASTRAL-5 (2 poster presentations)

The efficacy, tolerability and safety of Sofosbuvir / Velpatasavir in HIV / Hep C co-infection was presented. 106 patients were enrolled for 12 weeks of SOF/VEL therapy. SVR at 12 weeks was demonstrated in the majority of patients across the 5 genotypical variants assessed. 

ASTRAL-5: SVR12 rates by genotype.

•        Genotype                             SVR12%   (n/N)
•        Total                                    95%
•        GT1a                                    95%
•        GT1b                                    92%
•        GT2                                     100%
•        GT3                                      92%
•        GT4                                     100%

No patient experienced HIV virological rebound.

Side effects were similar to other available DAAs with fatigue (25%), headache (13%) and nausea (7%) reported. 

• Drug-Drug interaction studies demonstrated no clinically significant interaction with a wide range of commonly used ART regimes. The only exception is that of EFV. There was a 53% reduction in VEL levels and thus EFV is currently not recommended for use with Velpatasvir. 

These presentations highlighted the suitability of primary care teams to effectively manage HIV/Hep C co-infection. This community based, patient centric model of care will enhance our capacity to eliminate Hepatitis C among the HIV cohort within Australia. The combination of Sofosbuvir with Velpatasvir provides pan-genotypical efficacy, good tolerability and limited drug interaction with ART. These characteristics will further enhance the ability of HIV/HepC to be safely and effectively managed in primary care settings within Australia.