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.

Vincent Burns

Vincent Burns

Dr Vince Burns is a Registrar in HIV/Sexual Health Medicine at the Albion Centre, Sydney. He is also a s100 prescribing General Practicioner. Vince qualified Medicine in 1992 in England where he worked before emigrating to Australia in 2008. 

Start treatment if not already on it.

Normal delivery if VL < 50, planned cesarean section for VL 50-399, add iv ZDU if VL > 400

714 infants born to 527.

No breast feeding.

Mean gestation was 38 weeks, mean maternal age at delivery was 30 years.

87% reported heterosexual exposure as the mode of transmission.

32% of infants were HIV infected after birth at the beginning of the time period studied, reducing down to 1.5% currently.

Maternal HIV diagnosis was made before parturition in 49% at the beginning of the period studied, compared with 98% currently.

In the last 10 years, there have been 11 cases of maternal transmission.

These were primarily cases where the maternal diagnosis was not known, or there were tolerability issues with maternal ARVs.

We have seen a substantial increase in numbers of children born to HIV positive mothers over the last 30 years.

41 sexual health clinics across Australia took part.

Treatment uptake 63% in 2007, 79% in 2015.

Significant reduction in viral load over the same time period for those on treatment.

Female, injecting drug user, indigenous groups were twice as likely to have a detectable viral load on treatment.

322 men

Most likely, in order: gay friends, straight friends, casual partners, immediate family, work colleagues, other family.

52% disclose within 6 months of diagnosis.

Younger were more likely to disclose to immediate family, but not gay friends or casual partners.

More contact with people who had died of AIDS were more likely to disclose their status.

Support from peers was associated with more likely to disclose their status.

Peer support was the only factor associated with employing methods to alter sexual behaviour to prevent onward transmission.

Peer support was the only factor associated with likelihood of disclosure across the board.

2016 update on the National PEP guidelines.

Attitude by staff is a deterrent to people seeking PEP - this is often reported by people who have seroconverted and attended for PEP in the past (a message to staff in the emergency department).

Undetectable viral load? You need to be sure that the source is reliable (the devil is in the detail).

What drugs to use - Combivir is gone, we should all be using TDF/FTC or TDF/3TC.

3-drug PEP (DTG, RAL, RPV).

Prompts for NSW HIV Strategy - spike in notifications in 2012, increasing condomless sex, delays from infection to diagnosis, strong evidence for TasP, UN declaration to reduce HIV by 50%.

The second strategy had new evidence - early ART irrespective of CD4 count, 90% of people diagnosed on treatment within 6 weeks of diagnosis, evidence of efficacy of PrEP, 95% of those diagnosed on treatment.

Introduction of 6 monthly follow-up surveillance.

Enhanced data has been collected since 2014 on patients with a HIV diagnosis from 2013 onwards, and is ongoing.

Change from making HIV notifiable by laboratory to notifiable by clinician also, giving them the authority to provide information about their patients.

94% return rate on the questionnaires.

60% on ART in 2013, 84% on ART in 2016.

Of those diagnosed in 2015, 90% are retained in care 6 months post diagnosis, 87% commenced on ART within 6 months of diagnosis, and 75% reached viral suppression.

Currently around 88% of HIV positive patients are on ART.

500 HIV + men, 320 confirmed viral suppression for over 12 months, on ART long-term were asked to respond to the statement: “Being undetectable makes it unlikely that you can pass on HIV during unprotected sex.”

Only 25% believed that being virally suppressed made it unlikely that they can pass on HIV.

2 other studies supported these findings.

These are the patients we would expect are the most likely to know that they have low infectivity, yet consistently it appears they don’t.

Looking at the strength of ACCESS to look at the cascades of care.

National collaboration.

Automated data extractions.

Laboratory network captures 80% of people living with HIV.

De-identified viral load records.

Viral suppression taken to be < 200.

Mean age of patients was around 40 years.

Trends over time saw an increase from 71% to 87.5% of patients with suppressed viral load.

Those under 40 years were less likely to achieve viral suppression.

Similar outcomes in terms of gender.

These data reflect those engaged in care.

Improved health outcomes, and at community level reduced transmission risk.

Determine predictors of early treatment and monitor the rate of adoption of early treatment.

Data source is most of the 83 clinics in Australia, analysis by the Kirby Institute.

Include diagnoses from 2004 to 2015.

Excluded inconsistent or incomplete records.

863 patients in the analysis.

Median CD4 count was 500.

Viral load higher in the earlier time period of the study.

Predictors of early treatment were low CD4 count, high viral load, and later year of the study.

Sociodemographic characteristics were not associated with early treatment.

Treatment as prevention - if we treated everyone as soon as they became infected, they would not be infectious and over time HIV would go away.

Where are we with our 90-90-90 UNAIDS targets?

This equates to 27 million people on ARVs globally.

Currently we are about 40% of that number.

Testing is difficult for countries like Australia and the UK.

Countries show large variability in the proportion of those on treatment.

Less variability by country in viral suppression of those on treatment.

Treatment guidelines are also inconsistent across the globe, where not everyone has adopted treatment for all.

There is lots of data missing from countries, and this is very basic surveillance data.

About 20,000 undiagnosed in UK, uptake of testing is poor.

3,000 new infections per year, would be reduced to 1,000 if we met our 90% diagnosed target.

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The positives and negatives of porn: an overview of the evidence.

The focus is more around young people and heterosexual.

Average age to first see porn is age 13 for males, and age 16 for females.

Most men were watching porn at least weekly.

Gay porn contains a lot more condoms.

Men receiving oral sex much more commonly than women.

Young people report learning about sex through pornography.

Learning about sex was particularly reported by same-sex attracted individuals.

Not wearing condoms and STIs are linked to pornography use.

Women watching porn is often seen as a good thing for a relationship.

There are reports of pornography addiction but there is little evidence to support this, relying mainly on sporadic case reports.

People who are violent are likely to both perform violence and watch violence in pornography.

Body image - little research here to support anything.

Most research is poor quality, out of date, doesn’t look for causation.

Most look for harms, and if you don’t look for a benefit you’re not likely to find one.

Some people feel pressured into doing what they see in porn.

Most people in the industry will get one or two infections per month.

Same-sex porn can be limiting in terms of the stereotypes presented.

What benefits are there to porn?

A partner with a higher sex drive can have an escape, rather than pestering the other partner or seeking sex elsewhere.

Sex acts can be normalised, allowing them to feel comfortable with doing them.

Technically porn is not legal in Australia (hosting cannot be on Australian servers)

It is not legal under the age of 18 years.

Filtering can be applied by governments, parents, internet service providers, but there are problems with censorship - sexual health sites tend to get blocked for example, and other people’s opinions determine what you can watch.

If we had good sex education maybe people might seek out pornography less often.

It’s going to be around for some time, and everyone has an opinion about it.

Perhaps we need some way of being able to talk about it.

Looking at disclosure that one is on PrEP to potential partners and changes in sexual practices.

Interviews with 24 gay men were conducted.

Normalisation.

It can reduce difficulties in disclosing either partner’s status.

Disclosing to presumed negative partners didn’t always go well, probably because I was a bit too intense about it.

Being on PrEP gave them a feeling of not needing to disclose, which was quite welcome.

Reduced sero-sorting, sero-positioning, and sero-withdrawal.

There is more of a fluidity of where the sexual encounter may end up, and less of a script to read from.

There was a reduced concern/worry about HIV.

HIV meds could be seen as something that can enhance our sexual experiences.

Australia is leading the world in PrEP roll out, the numbers on PrEP are amazing.

40-50,000 new infections per year in US, disproportionately in MSM and blacks.

2012 the story begins.

25% of MSM aged 15-59 are PrEP indicated, that’s 1.5 million people.

25% of new infections are in whites, yet 75% of those on PrEP are white.

With 40% coverage and 60% adherence, we estimate one third of infections could be avoided.

It is important to bridge gaps between PEP and PrEP as it is common to acquire HIV meantime.

“The case for PrEP, or how I stopped worrying about and started loving HIV-positive guys”.

No evidence to indicate lower PrEP efficacy in the presence of STIs.

Those with the most STIs are the ones most likely to benefit from PrEP.

We can think of new ways for STI prevention.

“We did not come here to fear the future, we came to shape it.”

Novel delivery methods - people are getting PrEP from all sorts of places

Individuals who are younger with normal renal function have very low rates of renal compromise to the point where it doesn’t require monitoring.

Individual benefit as well as prevention benefits.

But do they really need to start that day, or does a few weeks matter?

Rapid intervention in the US combined the first few visits into one to initiate treatment earlier.

Of 227 patients in a clinic 39 underwent rapid initiation.

70% of participants had acute HIV.

All had no insurance.

90% opted to start ARVs on the first day.

1 in 4 required a change in their ARVs within the first 18 months compared to none who were not recruited on to rapid intervention.

The rapid intervention group still had to attend multiple times for a variety of reasons.

High dropout rates in the rapid intervention group.

PrEP has been used in NSW by high risk individuals since 2011, with a significant increase in 2016.

It has been limited by cost and availability.

Who should have access to PrEP, given limited resources? - The high risk patient approach.

Demonstration study - PRELUDE 2014-2016 government purchased generics

Estimated 4% (12 of 300) of PRELUDE study patients would have seroconverted, but none did.

Individuals are usually highly motivated.

Blood tests in these studies suggest very high levels of adherence.

The implementation trial EPIC-NSW.

Estimated that there must be 3700 high-risk individuals in NSW

It was estimated that the highest risk 11% of the gay community would comprise 3700 people,  but so far we have recruited 4000.

EPIC aimed to target this group and enroll them on a PrEP study.

EPIC-NSW estimates 150 participants should have seroconverted by the end of the study, it is early yet, but so far none have.

 

Epidemiology of Anal HPV and Anal Cancer

Overview of the role of HPV in cancer.

Over 100 different types.

HPV 16 causes over half anal cancers. Other oncogenic types together cause about 80% of anal cancers.

Infection with many types is common.

Over 40% MSM have HPV infection at any one time. More common in HIV positive, and more common again if immunosuppressed which makes clearance less likely.

Anal cancer increases with age above 45 years.

The rates are much higher in HIV positive MSM compared with HIV positive men.

In the current HAART era 3% of HIV positive MSM develop anal cancer, rates that equal cancers like colorectal carcinoma.

Screening was offered and readily accepted.

In HIV positive individuals there was almost twice the number of abnormal PAPs compared to HIV negative.

Abnormal cytology had high sensitivity but low specificity.

Adding HPV 16 + increases specificity.

 

What should we be doing for our patients now?

The HPV vaccines are a game changer.

Should we screen for early HGAIN (high-grade anal intraepithelial neoplasia)?

Similarities with cervical carcinoma, and that has a screening program.

There are key differences - larger area to swab, harder to identify lesions, different natural history (more high grade lesions less likely to progress to cancer), 40-60% would need to go on to high-resolution anoscopies, we need better treatments for high grade lesions.

Currently, more than 50% of anal cancers are visible externally, with an average size of 2.9cm, making them at least stage II disease.

Are we ready to screen for early cancers?

Can we implement early detection with an annual digital rectal exam?

Most HIV physicians think it is very important to screen for anal cancer, yet hardly any do.

Annual DARE (digital anal rectal examination) is well tolerated and an acceptable screening test for patients.

 

An update of the Study for the Prevention of Anal Cancer (SPANC)

High grade lesions are 5 times less likely to progress to cancer than cervical cancer in HIV positive men and 50 times less likely to progress to cancer in HIV negative men.

Mean age was 50 years.

Mean duration of HIV infection 15 years.

90% on treatment.

Almost all had CD4 nadir < 200.

Almost all were virologically suppressed.

After 1 year of SPANC the following findings:

The rates of HPV 16 were very high.

Clearance of this type is less than half of the other types.

Lesions were not associated with age or length of time infected with HIV.

High grade lesions were related to immunosuppression and lifetime anal experience.

New infection is common.

There is a high rate of 9-valent types in infections.

Over 50% of lesions persisted for 12 months.

Anal cancer is a huge and increasing problem.

 

Educating the community about HPV and anal cancer

AFAO (Australian Federation of AIDS Organisations).

The Bottom Line - campaign developed by AFAO to increase awareness of HPV and anal cancer.

Increasing awareness of HPV infection, DARE, anoscopy and biopsy, and information for those diagnosed with anal cancer.

Campaign materials included a web-site (www.thebottomline.org.au), 2 printed booklets for clinicians to give to their patients, poster.

 

A community perspective on anal cancer and anal HPV

Postal survey of how much respondents knew about anal cancer.

People thought their risk of anal cancer was the same as the general population.

People did understand what the symptoms would be.

Most had never discussed HPV or anal cancer with their doctor.

Of those that did discuss this with their doctor, it was the patient that brought it up.

One third of people would be really uncomfortable discussing this with their doctor.

76% had never been screened for anal cancer.

Most common examination was DARE, followed by high-resolution anoscopy.

84% hadn’t been vaccinated.

 

Living through the diagnosis and treatment of anal cancer

I was diagnosed with anal cancer in 2014, aged 52.

Diagnosed with HIV 1999, started ARVs 2005.

Having annual DARE because of family history of prostatic carcinoma.

Had surgery, then went back to work the following week.

Started chemoradiotherapy.

Looked after himself mainly, despite not coping well.

I needed to return early for a chemotherapy session, my liver was not functioning properly.

My skin was prickly, I was feeling nauseous, and it was recommended I admit myself to hospital.

Was told liver wasn’t working and I had to stop my HIV medication and pain relief.

I was released from hospital after 8 days, and prescribed bactrim, and had lost 20kg.

My CD4 count had dropped to 70.

I began my HIV medications again, and regained weight, but my kidneys shut down.

I had a problem with an overactive bladder throughout this (it was unclear what the cause was, my prostate or post-radiotherapy change). I was catheterised with a long-term catheter a few times, and developed a UTI.

My cancer has been cured.

My bladder has improved.

 

Questions

Is there a benefit vaccinating older people with early anal lesions?

There is evidence that early cervical lesions do have reduced recurrence following vaccination but no evidence yet for anal.

It is only funded for under 25 year olds, but if you can afford it, it is unlikely to do you any harm.

Should we be doing a DARE on HIV negative patients?

No, it is not cost effective, because it is not common enough.

If you’re going to do it, do it on a regular basis.

M. genitalium was isolated 30 years ago.

The organism is difficult to culture, and NAAT is difficult to access.

Commercial NAAT point of care testing is around the corner, so diagnosis is about to become much more accessible.

It has taken longer to establish its role as a pathogen because it is more commonly asymptomatic.

No evidence to support screening, just test those who are symptomatic.

Prevalence is about 1-3% of men and women.

Has similar clinical features to chlamydia.

Increases the risk of tubal abort and PID 2-fold.

 

No cell wall so not sensitive to penicillin-like antibiotics.

There has been widespread use of azithromycin for NSU symptoms, so macrolide (azithromycin) resistance increasing and is now at 50%, however it remains the first-line recommendation.

Moxifloxacin looked promising but resistance to this is now at 15-25% and increasing, currently for second-line treatment.

Guidelines concentrate on urogenital infection and don’t cover rectal infection.

Pristinamycin currently is our only other option, reserved for third-line treatment.

Worldwide we are seeing increasing notifications for syphilis and gonorrhoea.

This is despite effective treatments for both, with the caveat that resistance is emerging for gonorrhoea.

Why is this happening? Various theories.

What can we do about it? Infectivity, number of susceptible contacts, duration of infectivity.

Infectivity - use of condoms with oral sex? Little else we can do to influence this.

Number of susceptible contacts (the rate of change of sexual partners) - vaccinations, chemoprophylaxis (doxycycline)? Again, little else we can do to affect this.

Duration of infectivity - early detection and treatment (sexual history, is your practice gay friendly, doing the right test, point of care testing), strengthening partner notification? Yes, these are within our ability to affect change.

Most STIs are diagnosed in primary care.

Testing rates in primary care are low.

90% of Australians visit their GP annually.

We have the opportunity to affect change.

Hepatitis C was first discovered in 1989.

Overall worldwide prevalence of 2.8%.

Most infections are acquired parenterally, with a significant amount of vertical transmission.

A large well powered study showed a very low sexual transmission rate among heterosexual monogamous relationships (0-0.6%/year, condoms not required but should be advised that they will reduce the risk).

What about MSM?

Hepatitis C incidence in HIV positive MSM has increased exponentially.

Risk factors are intravenous drug use, condomless anal sex independant of intravenous drug use, and syphilis infection independent of intravenous drug use.

There is also sexual transmission of hepatitis C in HIV negative MSM related to chemsex who are on PrEP.

More likely with rough sex and fisting.

Reinfection rates are common.

Screening is recommended annually in HIV positive individuals.

In HIV negative individuals we probably don’t need to screen for hepatitis C routinely, but should consider it in people on PrEP.

Most studies from United States.

Traditional patient referral - patient tells partner go to the doctor, you may have an STI.

Assisted patient referral - patient uses some aid e.g. fact sheet, online notification websites.

Patient Delivered Partner Therapy (PDPT) - strong evidence that this was better than traditional patient referral, but no better than other assisted patient referral.

Considered safe - no episodes of anaphylaxis or major events.

Decreased the incidence of chlamydia and gonorrhoea in a US state by about 10%.

Some studies gave the medication, others provided a prescription for it to the pharmacist.

The prescription was taken up as readily as the direct supply of medication in studies.

Fewer than half of pharmacists knew PDPT was legal. Pharmacists may need training.

In Australia it was thought that PDPT could be used to obtain medication to disguise child abuse.

Consultations are underway to use a phone number on a prescription rather than the traditional patient address to facilitate PDPT prescriptions in some states.

How do we get this into primary care and get GPs to adopt it?

Rectal chlamydia is the most common STI in MSM.

Rectal chlamydia is more common than urethral.

Observational studies suggest doxycycline is more effective than azithromycin, but there is no evidence from RCTs

There is a move away from azithromycin to doxycycline.

 

There is much less evidence for mycoplasma genitalium.

M. genitalium was much more common in HIV positive men than HIV negative, accounting for 21% of symptomatic proctitis (as common as chlamydia) compared with 8% symptomatic proctitis in HIV negative MSM.

May be present in 4% asymptomatic MSM rectally.

M. genitalium is present in MSM and may be increasing.

Most are macrolide resistant.

Recommendations exist for urogenital infections, recommending azithromycin first-line, and moxifloxacin as second-line.

Until we have more evidence on how to treat rectal infections we will need to follow the recommendations for urogenital infection.

Third-line treatment is with pristinamycin.

There is a problem using monotherapy in these situations and we are likely to see resistance emerging.

Unfortunately synergy of pristinamycin with other antibiotics hasn’t been good.

Success rates using pristinamycin are about 85%.

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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