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.

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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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)

 

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.

HEPATITIS C VIRUS: GONE BY 2030?

John W. Ward, CDC, Atlanta, GA, USA

Recognizing hepatitis C virus (HCV) as a major public health threat, the World Health Organization in 2016 released a strategy for global elimination by 2030 (i.e., 90% reduction in HCV transmission and 65% reduction in HCV-related mortality). The United States (US) National Academies of Sciences has deemed US elimination of HCV a feasible goal.

HCV-Infected persons born during 1945-1965 are at greatest risk for HCV-related mortality. Certain strategies improve the HCV testing, care, and cure cascade and can reduce HCV-associated deaths. Provider education and adoption of clinical decision tools improve rates of HCV testing. Training and support of primary-care clinicians expand the workforce offering HCV services. Diagnosis of current HCV infection is improved by reflex testing of anti-HCV+ specimens for HCV RNA. Patient navigation services help persons begin and remain in care. At national and health-system levels, implementing policies and setting and measuring performance targets can improve quality of services. Issues with provider reimbursement for HCV treatment limit the number of persons treated through the Affordable Care Act and proposed changes might impact access to care. Creative solutions are needed for universal access to HCV treatment. Reducing US HCV transmission rate by 90% requires a targeted approach. Incidence is rising among persons who inject drugs (PWID); an increasing number of infants are born to HCV-infected mothers. Harm reduction services (e.g., clean injection equipment, drug treatment services) can prevent >70% of infections among PWID; HCV testing and treatment can enhance prevention. Access to these interventions is poor, particularly in areas with high HCV incidence. In the absence of an effective HCV vaccine, reaching elimination goals for transmission will require improved detection and investigation of transmission networks, increased availability of harm reduction services, affordable HCV therapies, and better evidence and capacity to deliver prevention services. Targeted intervention delivery to incarcerated and other vulnerable and marginalized populations is key to achieving elimination goals. With strong societal commitment and support for implementing comprehensive HCV prevention, testing, care, and treatment, HCV can be eliminated as a public health threat in the US.

Tagged in: CROI 2017

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