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.

Notes:

HPV associate with 90% of anal cancers. HPV 16/18 is associated with 92% of the HPV related anal cancers.

Being an MSM associated with a 40x risk of HPV anal cancer. Being an MSM who is living with HIV shows an up to 100x risk of HPV related anal cancers. 

Spanc study showed that while a percentage of men with self clear of anal HPV infection this is less likely with HPV 16 infection.

Despite treatment guidelines not recommending HPV vaccination in men older than 26 the SPANC study showed that many older men have not been exposed to HPV 16. This opens the suggestion that vaccination with 9 strain HPV vaccine may offer benefit beyond the age of 26.

The indigenous population of Australia is suffering with disproportionate levels of STI's. Risk are 3x for Chlamydia, 18 x for Gonorrhoea, 4x for Syphilis. Barriers have been identified for men to get STI testing including lack of information as well as culturally appropriate male health workers to engage with clients for testing.

There has been a significant rise in Syphilis infections within Northern Australia's indigenous population. Rates are similar in men and women in the younger age group 15-29 years old. 

Given risk of congenital syphilis and intrauterine death a robust testing campaign has been initiated to test all women of child rearing age as well as intensive screening of pregnant women. 

Testing in pregnancy includes up to 5 tests during pregnancy and if a female has had a positive test she is then testing monthly till delivery and followed for 3 months post delivery to ensure no reinfections.

Notes:

Indigenous Australians have a disproportionally higher levels of Chlamydia and Gonorrhoea compared to non indigenous Australians.

Point of care testing for Chlamydia and Gonorrhoea in Remote North Australia has proven to be highly effective in ensuring rapid diagnosis and treatment of those infected.

POC testing has reduced time to treat from average of 19 days down to 72% less than 3 days and the majority treated in under 7 days.

Real time testing of Ciprofloxacin resistance in Gonorrhoea is emerging with testing for genetic patterns associated with Ciprofloxacin sensitivity as well as resistance.

Pristinamycin is a novel new antibiotic with dual action that may prove to be helpful in treating macrolide resistant Mycoplasma Genitalium. In doses of 2- 4 g daily it has shown 75% cure rate in previously failed treatment of MG. Pristinamycin has shown an acceptable side effect profile and safety in pregnancy when given unknowingly.

New PCR test kits are emerging that allow the detection of MG resistance detecting 5 different genetic markers. This may aid better directly therapies for treatment of MG.

Changes in vaginal microbiota have been associated with increased risk of bacterial vaginosis.

Risk factors include, reduced levels of lactobacillus, increased exposure to different vaginal flora via new sexual partners, high levels of Gardinerella as well as changes in stability and increased diversity of the vaginal flora.

Female partners of men diagnosed with pathogen negative non-gonococcal urethritis should be notified, tested and ?treated with review of partners data showing increased rates of symptoms in female partners (60%) and a 12% association with PID.

 

Notes: 

Khadija Gbla's key note speech was fantastic. She has highlighted the importance of unpacking and going back to absolute basics when talking sexual health with people from culturally diverse backgrounds.

She has provided a timely reminder that we as Australian's are able to take many things for granted that others across the world, and those who have come to Australia may not have had access to.

It's important we "check out privilege" and stop to think were we are coming from as well as the recipient of the information we are hoping to share our message with.

 

Basil Donovan has well earned being the first recipient of the ASHA Distinguished Service Award. His work in sexual health with many of Australia and the world's best has changed the climate of sexual health in many profound ways.

 

Amber D'Souza gave a fantastic synopsis of the effects of the HPV virus in both men and women. She has highlighted the importance of vaccination for HPV and how prevention is an important tool against HPV given it's high impact on men who have sex with men in particular those living with HIV.

I was genuinely surprised to learn of heterosexual transmission of HPV, female to male, lead to marked rates of oropharyngeal cancers in heterosexual males.

Amber also gave a great preparation to later presentations on the relationship of HPV with anal cancers in MSM.

 

Finally a synopsis of new HPV screening, vaccination guidelines. Look out for 2 doses of 9 strain HPV vaccines in the near future.

Changes to cervical screening guidelines also highlighted.

Further details available at Future Changes To Cervical Screening Guidelines. 

 

Opening plenary was powerful  and a good example of the need for constant reflective practice:

with Khadija Gbla's ;

Discovering Sexual Health from a CALD perspective, addressing Sexual Health as a Human right, the need to reach out to all, LGTB et all, the need to be all inclusive

SexualHealth as a Western construct and the need to unpack that

Information is power!

The need to for currency of practice

Basil Donovan as ASHA Distinguished Service Awardee

Reflected on the past differing approaches by Family Planning,Sexual Health and organisations and how finally Service providers with ASHA are uniting  resources

Basil reflected on the need for the community to be more involved centrally

 the new shared  STI guidelines

the past work to decriminalise CSW

Looking back to the AIDs fear from 1983 

His early  Lancet articles and their timeliness

Indigenous Health review

Increasing POCT

ACCESS SURVEILLANCE :50 CLINICS Monitoring National trends and problem solving

The introduction and massive impact of the HPV vaccine: which carried through the days HPV presentations

The syhilis outbreak in Remote Australia

and the work needed ie chlamydia and less than 1/4 diagnosed

His message was TIMING is better than data

Again that strong message of ensuring reflective practice, and currency of practice

 

The plenary then aunched into all about HPV; oral to anal

Amber D' Souza; Rethinking HPV and Related Disease prevention

The changing epidemiology of HPV

Despite the HPV vaccination still greater than 5% of global cancers

Mindful that Australias HPV vaccination roll out and screening programme remarkable with 71% vaccinated zand acheived a herd immunity

UK 60.4%

USA 33.4%

Now evaluate to be able to continue in light of cost effectiveness 

Reseatch shows Number of vaccinations required for same HPV Ab response ;probably  2

What resource poor countries could use as rollout

The look at female and male vaccination in light of Public Health and cost effectiveness

Oral HPV 6x more common in males

Oral sex with females Increasing risk factor

.? HPV VL higher in cervical fluid than on penile shaft

Or reduced immunity

Males less likely to clear infections

But that sexual behaviour does not explain differnce re sex and HPV incidence

 

Marion Saville The National Cervical Screning Program; On the Cusp of Change,giving a VERY comprehensive overview on the new guidelines post the introduction of Gardasil in 2007

Giving caution of a global overview regarding discrepancy in surveillance between countries

Aust surveilance good

National Register for vaccination

High school coverage

GPs under notified older women

Still work to do in Indigenous and CALD communities as a continuing theme

Lowest 10% socio economic not getting to school

Safety of vaccine

Evidence of high levels Antibody response probably sufficient for life

Now vaccination offered to prevent secondary recurrence HPV

Looking at the 2 dose schedule

USA 9 valent vaccine approved

Hard to measure success, more adjuvent more pain

Probably will be the same in future for Aust re cost effective

Outstanding success cervical screening program

BUT Took 40 years from pap to be recognised as imporant scrreening tool

Frazer and HPV vaccination

But now need to address EQUITY

Modelling suggests 30% reduction cervical cancer on top of vaccination

Outlined new guidelines with new technologies

Self collection

Caveat no change to incidence adenocarcinoma only squamous cell Ca

Discussed quality improvement and COMPASS Trial

Carried through to afternoon session Clinical Sexual Health and Epidemiology:Anal HPV

And non clearance of Anal HPV in males esp HPV16 increased with age

No difference if HIV

2 HPV tests at least 6 months a part may identify male with persisting chronic HPV and the increased risk of Anal cancer

screening moving to HRHPV testing 

Ongoing research toward cost effectiveness and best practice and equity...

Amber D'Souza, Associate Professor, Johns Hopkins Bloomberg School of Public Health, USA gave a fantastic talk in the opening plenary today in Adelaide.

She talked about HPV causing >5% of cancers worldwide, >600,000 globally mainly cervical cancer.

12/100,000 - Cervical

8/100,000 - Oral

2/100,000 - Anal

She told us that the uptake of the HPV vaccine in Australia is 71.2%, UK is 60.4% but only 33.4% in US were there is no school based program and in 2014 the vaccine was available in over 75 countries but many low income countries are still missing the vaccine program.

Interestingly in the US they've seen a growing number of HPV positive oropharyngeal cancers especially in men. 2.4% per year in men 45 years and older but only 1% per year in women 45-64 years but all other head and neck squamous cell carcinomas have reduced ?due to reduction in smoking.

She said the lifetime risk of oral HPV infections in men was 3-30% but only 1-8% in women and one of the reasons why could be that cervical fluid has a higher viral load than the throat?

Risk factors were recent oral sex in last 3 months and the risk increased if the man had performed oral sex on a woman rather than a man. But interestingly, HPV is low in lesbian women which suggests that women get an auto immune response to previous HPV infections.

Gender - there is a 5 fold infection rate in men compared to women.

Race - HPV is higher  in white men compared to black or Mexican American men, does this mean that white men have more oral sex?

So with the same number of lifetime partners, men have a higher risk of orophryngeal HPV and a lower rate of clearing the virus.

Then she told us about Anal cancer that effects 2/100,000

Risk factors include receptive anal sex and in MSM 10-20/100,000 are +ve for anal HPV, that number is higher in HIV+ve MSM and these figures are increasing by 4-5% per year in US and Australia

Clearance usually takes 1-2 years 

She then went on to talk about the effects of HIV on HPV were the acquisition of HPV is higher in anyone with immuno suppression and clearance is less likely. The rate of HPV in people with HIV is 60%

In 2001-2005 29% of men with anal cancer also had HIV, making anal cancer the 4th most common type of cancer in HIV +ve men 

She summarized by saying that the changing landscape of HPV and related diseases needs to focus on prevention and screening for HPV DNA.

 

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