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.

Professor Rebecca Guy (Program Head and Professor, the Kirby Institute UNSW) gave a very illuminating presentation on the epidemiological mechanics of elimination programs and the areas that will need to be focused on if Australia is to achieve elimination of hepatitis C as a public health problem.

These areas were outlined as Modelling, Obtaining data at a finer geographical level, Developing better health service delivery data, Understanding barriers to assessing services, Monitoring of new cases and Improving completeness of indigenous data.

Of particular interest was the need to understand where new cases are coming from as this will help identify where our prevention strategies are failing and where we need to focus our efforts.

Notification of RNA data was suggested as a way for better identification of new cases.

Read more about other speaker presentations in this AVHEC17 session


The global impact of chronic HBV cannot be underestimated, with 257 million people affected. More people die from chronic HBV compared to HIV/AIDS or malaria.  


Dr. Samuel So has launched a world-wide campaign with JoinJade, which aims to educate and engage people in the community, to increase awareness in order to achieve elimination of hepatitis B and thereby decreasing mortality and morbidity. 


The goal is to eliminate hepatitis B and C by 2030, and although this sounds ambitious, it is not impossible.  He recommended engagement of the government to coordinate stakeholders including the criminal justice systems to treat correctional facility inmates, professional organizations to treat patients in primary care and the CDC and local health departments.   


In the US, Asians and Pacific Islanders make up 6% of the US population, and these groups make up more than 60% of chronic HBV in the US.  In Australia, we see an increasing number of migrants from endemic countries and in the NT, most cases of CHB are made up of Indigenous and the CALD community.   


He initiated the campaign in Qinghai, China and this led to the Chinese government adapting a national vaccination program for hep B, and his efforts should be lauded.


His Jade Ribbon campaign has reached Australian shores, and hopefully this will lead to a better community engagement with regards to awareness, as well as better primary care involvement in identifying and treating patients with CHB. 

His talk ended with a video of Jackie Chan encouraging people to get tested and treated.


Link through to Prof Samuel So's speaker presentation here


JoinJade: Access the campaign here


I am reporting from oral abstracts being presented at AVHEC17 regarding understanding the epidemics (modelling and surveillence).


The first talk , presented by Dr B Hajarizadeh (Kirby Institute, UNSW Sydney) , outlined results of Surveillance and Treatment of Prisoners with Hepatitis C (SToP-C) in New South Wales. This study was conducted in 4 prisons and revealed high HCV incidence in residents. It was confirmed that in almost all cases HCV transmission was primarily associated with intravenous drugs use. Prisoners almost always share needles so reinfection levels are twice higher than for primary infection. This study concludes the importance of introduction of wide preventive strategies including treatment as the very important part of prevention. 


Jenny Iversen (Kirby Institute, UNSW Sydney) stressed the importance to monitor progress towards elimination of Hepatitis C infection in Australia. The Australian Needle Syringe Program Survey (ANSPS) examined treatment within PWID over the last 5 years to ensure quality of care . The study included self-completed questionnaire and dried blood spots serological testing.  Associated factors (like age, gender, geographic location, frequency of drugs injections etc.) were also included in the study. This study was demonstrated high involvement of PWID with Hepatitis C infection after introduction of DAA under PBS. Further plans include recommendations for the RNA testing to confirm spontaneous and treatment induced clearance. 


Amy Kwon (Kirby Institute, UNSW Sydney) presented Part of BBV & STI Research, Intervention and Strategic Evaluation Program hold in Australia to assess level of DAA required to eliminate Hepatitis C by 2030. Using mathematical model and three possible scenarios (optimistic, pessimistic and intermediate), it was concluded that Australia finally will meet the WHO HCV elimination targets in 10-13 years. Australia invests around 1 billion dollars (2016-2020) in elimination program without restrictions on stages of Liver disease. The treatment mostly includes DAA with no Interferons; re-treatment is also allowed. Some limitations – like internal migration or reinfections – were also taken into consideration, however would not have crucial influence on the process of elimination. 


Recommendations for HCV testing were presented in a talk by Dr Nick Scott from Burnet Institute. He focused on models of care, treatment scale-up and care cascade among people who injects drugs in Australia. The suggestion was given for the additional testing (PCR test) to the HCV RNA. Effectiveness of such combination was confirmed statistically along with annual frequency of the testing. Such improvements in the testing system will make possible to achieve the WHO elimination target and minimize the likelihood of future outbreaks. 


Kelly Hoskins (Continuous Quality Improvement Facilitator, Northern Territory Government) presented data about Hepatitis B infection in the Indigenous populations. The prevalence of HBV infection within Aboriginal community is much higher (up to 12%) than in general Australian population (1%).  The project targeted on identification of those who are chronically infected and who never undergone HBV testing. The process was piloted in 5 Aboriginal communities and involved data collection and testing. The part of the project was also created (pointed?) to increase educational opportunity for the GP and other primary care providers for the proper Hepatitis B care with big attention  to find all Chronic Hep B clients and engage them to the care.  


Ms Maryam Alavi (Research AssociateKirby Institute, UNSW Sydney) talked about the 

burden of liver disease and comorbidities within PWID. The study revealed the importance of continuing to increase access to screening, care and treatment for individuals affected .  


The final presentation by Karen McCulloch (Research FellowUniversity Of Melbourne) 

characterized populations with Hepatitis C to improve access to antiviral therapy programs. This study evaluated comorbidities and other characteristics of people who are current PWID and non-PWID in NSW. The higher rate of comorbidities was reported in people with HCV infection so longer hospitalization was usually needed in case of inpatient care.


Link through to oral abstracts and speaker presentations here

This was an interesting oral abstract session regarding community knowledge and approaches to pre-exposure prophylaxis.  PrEP was discussed in detail and covered topics like barriers to uptake of PrEP, preferences for prevention technologies, measuring adherence in PrEP users and how the health system and study designs of PrEP trials can facilitate rapid enrolment of those at high risk of HIV acquisition.

The first speaker was Adeline Bernier from France.  Although PrEP is already available in Norway and France through government subsidised programmes it has not been widely taken up in the rest of Europe.  She presented results from The Flash! PrEP in Europe (FPIE) online survey.  This was a community-based research study aiming to assess interest in and barriers to PrEP uptake amongst respondents from 11 European countries.  They found low knowledge of PrEP amongst at-risk groups, high interest in PrEP but low uptake.  Most commonly cited barrier to taking PrEP was fear of side effects.

Darrell Tan presented results from an MSM survey conducted with those undergoing routine HIV testing.  They asked questions regarding preferred method of PrEP delivery (oral, injectable, topical) and whether the reliability of different technologies would influence their decision on which method to use.   The results were many and varied.  Further analysis is required to understand what influences each individual’s preference for PrEP.

James Ayieko from Kenya presented results from the ongoing SEARCH trial, 18% of 4,064 participants took up the offer of PrEP within 30 days.  Participants’ perception of own risk did not always match that from a risk score.  This indicates further community-based education regarding risk is required for those considering PrEP.

Edwina Wright presented data from the Melbourne cohort of the PREPX trial. Recruitment to the PrEP trial was facilitated by a high community PrEP awareness and involvement of GPs and Pharmacists who were remunerated for their services.The high PrEP awareness in Australia contributed to the high enrolment of the ongoing PrEP study.

Rupa Patel presented data from a US study which found a good correlation between adherence measured by 3-month MPR (medication possession ratio) and 7-day self-report with TFV-DP (tenofovir diphosphate) blood levels in DBS (dried blood spot) of MSM taking daily oral PrEP.  The good correlation of the 3-month MPR and 7-day self-report with biological measures of adherence in PrEP users suggests that this could be ideal for measuring adherence in the clinic setting.

Hanne Zimmermann from the Netherlands presented data from a longitudinal semi-structured interview in MSM using PrEP.  This revealed that MSM switched between daily and event-driven PrEP use or even stopped PrEP based on their personal situation and risk exposure.  Individuals made decisions on PrEP use based on perception of their own risk.  The authors concluded that in order to successfully support future PrEP users, a tailored approach, addressing choices for PrEP regimens as a continuum of flexible and changeable choices, is essential.  Appropriate education would be an essential part of this strategy.

Day 3 of the conference and PrEP of course has been the 'hot topic'

This oral abstract session was a reminder that there is more to prevention than antiretrovirals however.

First up, Kelly Kilburn gave evidence from the HPTN 068 study in South Africa where a third of women experienced physical violence by a partner. And there are direct correlations between this and HIV transmission.

The experiment involved 2,533 women between the ages of 13 to 20 years. They were randomly assigned to one of two groups where one group of girls (or their parents) received approximately $10 USD if they attended at least 80% of school days in the past month. Participants then completed a self interview and HIV and HSV-2 test each visit and at 12, 24 and 36 months following. The questionnaire was able to distinguish between sexual and physical intimate partner violence (IPV). 

The conclusion was that the conditional cash transfers had no significant effect on sexual IPV, HIV or HSV-2 acquisition. There was however a significant risk reduction for physical IPV by 34%. It was interesting to note that there was 95% attendance in both arms of the study and that the cash payment had no effect at all on school attendance but may have given the young person the independence from a violent intimate partner. 

I took a few interesting points from Shona Dalal of the World Health organisation that will be useful to my practice. She presented a systematic review of HIV partner notification services. Assisted versus passive notification where there were varying types of active notification - contract, provider or dual referral approaches. Contract is where the HIV positive client enters into a contract to disclose their status within a certain time frame and advise their partner to have HIV testing. Provider is where the provider confidentially contacts the HIV positive clients partner and offers voluntary testing. Dual referral is where the provider accompanies the HIV positive client to assist whilst they disclose their status and voluntarily offer HIV testing services.

With all types of notification if it didn't occur within a week it was less likely to occur. There were very few reports of harm and there was increased linkage to care and treatment among partners.

There was a talk from Sean Allen regarding a change in the policy of syringe distribution in Baltimore, MD from 1 syringe given for 1 returned to as many given as required. The number of syringes distributed doubled but the average number of HIV infections per month reduced. 

Also covered in this session were male circumcision and its effect on transmissions to women of sexually transmitted diseases. And also community based distribution of oral HIV testing kits aiding the early diagnosis and treatment of men in Zambia. 

Phew - what a session!


Tagged in: 2017 IAS Conference
Twitter response: "Could not authenticate you."