William Hooke

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.

William Hooke

William Hooke

As a registered nurse at Clinic 16 (North Sydney) I see a mixed caseload of clients for HIV/BBV/STI testing and treatment. Prior to and concurrently throughout my nursing I spent up to four years working with ACON (LGBTIQA+ Community organisation) as a volunteer and then as a Peer Educator for aTest (Point of Care HIV testing) conducting rapid HIV tests. I am currently enrolled in my Masters of Public Health and have a strong interest in changing STI treatment guidelines.

Posted by on in Public Health and Prevention

How do you summarise such a comprehensive and jam packed conference into one post?!

 I have been absolutely overwhelmed by the great presentations and seeing such wonderful colleagues from around the world share their research to everyone.

 Some of the main highlights for me were the Doxycycline as prevention plenary which had a great discussion post presentation from a lot of clinicians around the world, but overall good to see the willingness to possibly adopt a new strategy with condom-less STI prevention.

 I engaged in Twitter posts throughout this conference (NB: #stirio2017 was the second most trending tag in Brazil), which I noted was quite popular among a lot of speakers and presenters to share information back home. Even seeing some of my tweets liked or re-tweeted by people from BASH or the Lancet was great to see how quickly the sharing of information between colleagues can happen. This was an exciting approach to disseminating conference material for those who couldn’t attend.

 A common theme I found was discussions around the antibiotic resistance in Mycoplasma and Gonorrhoea, and how appropriate testing and prescribing practices, specifically around not using Azithromycin with rectal chlamydia are really important to bring inline uniformity to treating as based on the WHO treatment guidelines.

 PrEP implementations are varied worldwide, and you can see how much funding and stigma around getting TDF/FTC out to communities is quite difficult in different political landscapes. There were so many posters presented and some great questions were posed around PrEP in relation to STI’s and Hepatitis C.

 One of the final presentations from Tetyana Vasylyeva (Ukraine) was quite moving considering the research was based on changing opinions on HIV prevention in the landscape of countries facing war. With a high amount of IVDU and a cut on all methadone programs at the time of the civil unrest in Ukraine, larger numbers of migration changes into already high prevalence areas without primary health resources, are increasing risk of HIV transmission.

 Currently in Ukraine they have over 220 000 known HIV + people with only 28% ARV coverage. Post war data showed over 1.7million people are currently displaced and with migration patterns changing, and cuts to public health funding this is making ARV programs difficult to sustain.

 I had hoped to catch up with Tetyana after the talk to ask more questions but like others, most people were running between rooms to catch different talks.

I've also attached some of the posters I enjoyed reading as well.

 I am so humbled and honored to have been selected as a scholarship recipient for ASHM, it has enhanced my knowledge significantly and after seeing a large number of clinicians in Rio, I hope further sexual health nursing members are able to attend in the future to bring relevant information back to their colleagues.

 

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This morning I attended the Oral presentations for HIV/STI testing and management, looking at different studies around HIV risk.

Brendan Harney from Melbourne presented his study: Risk of HIV following repeat sexually transmissible infections among men who have sex with men in Victoria, Australia. 

This presentation was a retrospective study questioning, if MSM have repeat positive STI diagnoses, are they at an increased risk of HIV transmission? 

Out of 8941 MSM (median age 29, Australian born) surveyed at a busy Melbourne Sexual Health Centres, 2.5% were diagnosed as HIV positive.

Although repeat Chlamydia and Syphilis notifications were common, Rectal gonorrhoea was found to be the highest, with 13.5% of those with a repeat positive gonorrhoea rectal infection becoming HIV positive.

Conclusion? Repeat Gonorrhoea infections are strongly associated with a HIV infection, and that this data is key to looking at PrEP inclusion criteria and why we target specific groups and behavioural activities for PrEP enrolment studies. 

 

Does Doxycycline Prophylaxis have a future?

The short answer from Jeffery Klausner (UCLA, CA) is; Yes.

Jeffery spoke about the two studies and looked at those results.

Antibiotic prevention is nothing new; Rheumatic fever, travellers (Malaria), Lyme Disease, or Travellers Diarrhoea. 

With increasing Syphilis rates in MSM and the risk of facilitating HIV transmission, Doxycycline Prophylaxis could defiantly have a place.

As we already know, Doxycycline is a narrow spectrum antibiotic that is inexpensive.

Two RCT's were conducted; one study looked at daily 100mg Doxycycline for 30 men over 48 weeks (not behavioural intervention), on average most had 1mg/ml in samples with only a few having undetectable levels (?non adherence) which overall showed good levels.

  • 73% reduction in Syphillis
  • 70% reduction in other STI's (Chlamydia)

Study 2: On demand Doxycycline as PEP. RCT in HIV negative men on 200mg single dose up 24 hours after sex, maximum 72 hours post sex. NB: No more than six pills per week.

  • 70-73% reduction in Syphilis and Chlamydia infections.
  • No effect on Gonorrhoea. 
  • Noted increase in GI side effects, (nausea, GI pain and vomiting), nil adverse events.

Both studies showed great results, but more research needs to be done (Australia is part of a trial at the moment), and concerns around long term safety as well as ?Resistance (MRSA) were raised.

Overall a great presentation looking at the future of condomless prevention of STI's in a time where we have over 6000 MSM using condomless HIV prevention in NSW (EPIC, NSW)

 

Why are some common STI's neglected over others? 

Gwenda Hughes from the Centre for Infectious Disease Surveillance and Control at Public Health UK spoke about the surveillance of neglected STI's this morning. 

On average every year, there are around 358 million new infections of four curable STI's, which one do you think is the highest number?

Syphilis, Chlamydia, Gonorrhoea, or Trichomoniasis?

6.6 Million Syphillis infections, 78 Million Gonorrhoea, 131 Million Chlamydia and at the highest; 143 million Trichomoniasis.

Caused by the parasite Trichomonas vaginalis, it is nine times more prevalent in women and with the associated risk factors of lower socio economic factors, lower levels of education and increased number of partners.

With poor specificity on wet smears, limited surveillance data, and knowledge gaps in racial ethnic disparity target groups, this is an STI that would benefit further research. 

In Sydney we do see limited infections, and this is more common in rural Australian settings, and higher amount in Aboriginal Torres Strait Islanders. 

Lymphogranuloma Venerum  (LGV) - is commonly tested in Australia with positive rectal CT infections, but one point I thought was interesting the presentation was in Germany that out of 154 MSM with positive CT infection not only had 17% had LGV rectally, but 15% had pharyngeal LGV.

Would this number be similar in Australia with the Sydney study (David Templeton) showing 3 out of 75 positive LGV with rectal CT. 

Could we do pharyngeal LGV testing with positive CT Pharyngeal PCR swabs?

HCV Infections in HIV negative MSM on PrEP

I attended the oral presentation sessions today on STI Surveillance with four different speakers on the topics of

  1. "A tale of two halves, low extended-spectrum cephlasporin and high azithromycin resistance in Neisseria Gonorrhoea in Europe,2015.
  2. Predictors of Persistent and Recurrent genital STI symptoms at sentinel surveillance cities in South Africa.
  3. High Prevalence of Hepatitis C Virus among HIV negative MSM in Amsterdam PrEP project.
  4. Origin and predictors of early repeat infections among HIV negative women with TV receiving a stat dose of 2g of Metronidazole. 

I will speak mostly about the HCV study in Amsterdam, but I just wanted to quickly mention number one. Each topic was around 15 minutes long, so limited time for questions or follow up.

1. Michelle Cole from GASP (Gonococcal Antimicrobial Surveillance Program) spoke about how they are testing resistance to gonorrhoea with Ceftriaxone, Cefixime and on every third year Gentamicin.
- Overall 2134 isolates were submitted from 24 countries and 1 x Ceftriaxone resistance was found.
- Five isolates had high Azithromycin resistance in 2014, and there was a high amount of resistance found in Heterosexual men and MSM compared with females.

Conclusions; high but stable resistance to Azithromycin and low overall resistance to Ceftriaxone and Cefixime. The speaker had raised discussion points around possible resistance; ?Mono Therapy, Azithromycin for NGU or the high use of Azithromycin in general?

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3. Roel Achterberg - Amsterdam, spoke about the study looking into HCV prevalence in HIV- men, specifically looking at the PrEP implementation program.

It was discussed that over the years, HCV emergence was noted in HIV+ MSM, not knowing why HIV- men were unaffected, questioning Biological, behavioural or network factors? The research question was asked; Is there HCV prevalence among MSM and Transgender persons starting PrEP, and do they cluster with HIV+ MSM?

Participants had a choice of daily or Event required PrEP (not available in Australia under trial). All were tested with HCV Antibody and HCV RnA.

  • 376 participants 
  • 18 Participants HCV+ (Ab and RNA)
  • 1 RNA+ but Anti HCV Neg, 14 RNA and Anti -HCV pos, 3 HCV RNA Neg anti HCV pos.
  • People with HCV reported more CLARS than others who were HCV negative.
  • Chemsex was a high component.

Conclusion from the speaker was that HCV prevalence was higher than previously found with HIV negative MSM.

As EPIC data in Australia is still being collected and reviewed by the Kirby Institute, it will be interesting to see how our data compares to Amsterdam.

I spoke to Roel after the presentation and asked about continual testing and study with PrEP and if they noticed behavioural changes or rates of infection throughout PrEP, but this data was still not available for them also.

 

This morning started with a great presentation of two Plenaries, starting with Vaginal Microbiome Research by Jeanne Marrazo - ISSTDR President and Professor/Director of Infectious Disease at University of Alabama - Birmingham. The Plenary followed was PrEP implementation, covered by my other colleague, Tamara. 

Jeanne spoke around the importance of healthy vaginal Microbiome and the increased risk of acquiring HIV/STI's. Some of these topics are already known, but it's good to re visit the importance of education to clients and to increase health literacy.

The benefits of having an optimal vaginal environment will see lower levels of HIV in women, protection from pathogens such as Bacterial Vaginosis (BV), Chlamydia, Gonorrhoea and TV as well as optimal birth outcomes such as a normal birth weight, timing of delivery and fewer pregnancy associated infections.

What is optimal vaginal environment? <4.7ph is optimal and anything above would be consistent with BV, in line with other symptoms (NB: STIPU Australia say >4.5ph).

Jeanne discussed that overall, women with BV have a 60% higher risk of acquiring HIV through vaginal sex, and men who's female partner is HIV+ are more likely to acquire HIV if those women have BV. On this note, Jeanne also mentioned that yes BV is quite common in Sub Saharan Africa, and can considered "normal" but it's not optimal.

In conclusion, further research is needed and more data around HIV/BV transmission risk to women. An important point was raised at the end around PrEP (TDF/FTC) implementation in women, especially around vaginal mucosa versus rectal being less effective in early administration and also studies are showing Tenofivir can have reduced coverage when Gardnerella Vaginalis is present.

The second plenary by Sinead Delany-Moretlwe (blogged by Tamara) spoke about Tenofivir effectiveness in women and it showed a lower tolerance for missed doses in the female genital tract in comparison to protection in rectal tissue acquired much sooner. 

With PrEP studies in Australia mostly recruiting MSM, it's interesting to look at female vaginal health in relation to PrEP, considering future prescribing options and the importance of education around HIV risk, STI reduction strategies.

WHO STI Treatment Guidelines 2017

 

Good morning from the 2017 HIV/STI Conference in Rio De Janeiro. There may be a cross over in some topics with other ASHM bloggers but over the course of the congress we will be blogging about different items.

This morning commenced with WHO treatment updates and guidelines, which had not been updated since 2003. The WHO updated guidelines and their objectives focused on ensuring they have international guidelines for the effective treatment of Neisseria Gonorrhoea, Chlamydia Trachomatis and Syphilis.

The majority of all treatment guidelines have already been adopted by Australian STI Management guidelines (STIPU) and are in place, but the key points taken will be outlined below.

* Neisseria Gonorrhoea (Assoc. Prof. Magnus Unemo - Director Swedish Reference Lab) - Dual Therapy (Ceftriaxone 250mg IMI with Azithromycin 1g Oral) recommended in all cases (Ano-Rectal, Oropharyngeal and Genital), unless resistance to Azithromycin is known, then single therapy with Ceftriaxone 250mg or Cefitixime 400mg can be used but again this only in specific cases and specialist advise should be obtained.
NB: STIPU do recommend 500mg Ceftriaxone IMI as do a number of other clinics worldwide. 

- Reinfection is treated again with dual therapy, but consideration could be given to treat with 500mg Ceftriaxone IMI with 2g Azithromycin Orally.

* Chlamydia Trachomatis (Nicola Low - University of Bern)

Guidelines were again similar to what STIPU guidelines in Australia recommend with a strong enforcement around Doxycycline versus Azithromycin in Ano-Rectal cases.

- 1g Azithromycin oral for Uncomplicated genital infections or Doxycycline 100mg Oral twice daily as alertantive treatment.

- Ano Rectal infections, there was a important point about ensuring Doxycycline 100mg BD for 7 days was used as first line treatment, and that Azithromcyin not be used as a treatment option. 

- For LGV, Doxycycline 100mg BD for 21 days is now recommended treatment versus the previous 14 x day treatment. 

- An important change from the 2003 guidelines was that Erythromycin was considered first line treatment in pregnancy, but now Azithromycin is the recommended treatment for women with a Chalmydia infection during pregnancy.

It should also be noted that Nicola Low mentioned there was not enough evidence for Azitrhomycin extra dosing to be used to treat Ano-Rectal Chlamydia as previously done for patients who might have had issues with Doxycline dosing adherence.

Treponema Pallidum (Syphilis) - Dr. Francis Ndowa (Zimbabwe).

Australian STIPU guidelines already reflect current guidelines.

- Early Syphilis -  2.4million units (1.8g) Benazthine Penicillin IMI as a single dose is still recommended as first line treatment or Doxycyclinne oral 100mg BD for 14 x days if there is a Penicillin allergy. 
(NB: Numerous other alternatives given, but not enough information was transcribed to write about)

- Late Syhpilis (>2 years) - 1.8g Benzathine Penicillin IMI as three doses spilt into 3 x weeks (i.e.: Every seven days), which is current to Australian guidelines. 

Genital Herpes Simplex Virus (HSV) - Prof. David Lewis - (Australia).

19.2 million new HSV2 diagnoses in 2012 for people aged 15-49 (11.3% Global prevalence)

6 x recomendations which show commence treatment straight away on first initial episode. Evidence showed a reduction in symptoms 2-4 days less than placebo and HSV shedding in 9.2 days
NB: See Brett Hadlow's blog for information around medication dosage recommendations).

For cases under four occurrences a year, treatment again is recommended with a 2.5 day reduction in viral shedding.

For cases over four reoccurrences, repressive therapy is recommended over suppressive and a twice daily dose of Acyclovir (400mg) or 500mg Valaciclovir once daily. Evidence showed less frequent HSV occurrence, and reduced shedding.

Overall it was good to see Australia is working within the WHO guidelines to combat STI prevention and ensure appropriate treatment.

For current Australian STI Guidelines, please see http://www.sti.guidelines.org.au

Photo 1: Blogging in my hotel room with Brett Hadlow looking over Barra Da Tijuca Beach.

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