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.

 

 

On Day 3 of the Glasgow Congress, Dr Teymoor Noori from the ECDC in Sweden spoke about his organisation’s efforts to increase HIV testing rates among MSM during European HIV Testing week in 2015 and 2016 using pop-up messages on mobile phone apps.  In the EU, MSM account for over 40% of all diagnosed cases of HIV, and it is the only group where increasing HIV rates are being observed.  

 

The ECDC rolled out push messages for a one-week period on commonly-used hook-up apps – Hornet, Planet Romeo and Grindr – which linked to the AIDSMAP website where users could locate their nearest HIV testing facility.  In the week of 23-29 November 2015, they had over 70,000 page views, although it was not possible to track whether this led to increased testing.  In 2016 they are planning to expand the message to include viral hepatitis and STI testing sites. 

 

This intervention was large scale and was free, due to the enthusiastic support of the CEOs of the app companies approached for improving public health initiatives.  There are plans to work together with app owners to creatively embed test finders in their apps.  A lot of work has been done in this area by the Terrence Higgins trust and SOAIDS in Sweden, who are developing guidelines for sexual health and HIV organizations to cover issues related to promotion, education and marketing via social media, mobile apps, and the internet. 

 

Tarandeep Anand from the Thai Red Cross AIDS and Research Centre, Bangkok, gave a fascinating presentation on the use of the internet and public apps to address the HIV epidemic in Thailand, where 1 in 3 MSM are HIV positive.  Studies have shown that MSM and transgender people in Bangkok spend an average of 7-8 hours per day online, and are accessing the internet on average once every two minutes.  The website Adam’s Love is being used as an electronic health record portal to screen high-risk populations for PrEP, book clinic appointments (using the Eventbrite system), provide free online counseling, and provide test results and customized daily reminders to take tablets for PrEP.  Tarandeep commented that there has been more success adapting already-popular websites to provide these services rather than custom-build health websites or private apps. 

 

Later in the morning, Dr Francois Houyez, from the European Organisation for Rare Diseases in Paris, spoke about the use of medical apps and privacy issues.  He stated that medical data is high in the list of favoured information targeted by hackers, according to IBM, and legislation related to the use of new technology in this area is evolving and is still “catching up” to new uses.  

 

Dr Laura Waters talk on HIV treatment cascade and other HIV population prevention/treatment issues.

 

2020 goals aiming for 90% of people with HIV diagnosed/90% diagnosed on treatment/90% on treatment undetectable - corresponds to 74% of those with HIV having undetectable viral load.

  •  Currently (globally) only 32% of those with HIV are on treatment with undetectable VL.

 

June 2016 paper (Lazarus et al) on adding a “fourth 90” to the 90-90-90-90 targets; that 90% of those on ARVs with undetectable VL have good health-related quality-of-life. Especially pertinent considering incidence of co-morbidities and ageing HIV-infected population (in developed countries).

 

2016 research from Toronto (Wilton et al) on high-risk populations and perception of risk studied 420 MSM who were objectively high risk:

 

  •       68.3% didn’t perceive themselves to be at moderate to high risk
  •      23.6% unaware of PrEP
  •      40.1% unwilling to use prep
  •    47% lacked a family physician with whom they could discuss HIV issues

 

 

Survey of Glasgow2016 audience on new directions for treatment - 40% of attendees believe that non-oral ART will be first-line by 2026.

 

Transmitted drug resistance by geographical region (START trial) - Australia highest (17.5% had any transmitted drug resistance)

The Lancet Special Theme Issue:  HIV, Viral Hepatitis, and TB among Prisoners

Lancet July 2016 issue has been dedicated to prisoner health, with more information online available from the Lancet website.  It is a sincere hope that this issue and discussions raised at this conference will influence the care of prisoners around the globe.

 

In this sessions the lead authors presented: a global review of the burden of HIV, viral hepatitis and TB among prisoners; clinical care among incarcerated women and men; best practice for prevention in prisons and jail; human rights and right to health access; and two region-specific presentations- on prisoners in Eastern Europe and Central Asia and Sub Saharan Africa.  Kate Dolan from UNSW presented on the Global epidemiology of HIV, HCV and TB in prisoners.

 

Annually 30 million people are passing through some form of detention.  These people are at high risk of acquiring and transmitting infections due to risk that are in play before and after incarceration.

Developed nations are not leading by example with US having the highest incarceration rates in the world, with blacks over represented  in the prisons.   Only eight countries have needle and syringe exchange programmes in prison.  The focus of incarceration should be rehabilitation. 

There is a moral and legal imperative to provide appropriate care to prisoners.  Only by including them and other marginalised populations in the global HIV/AIDS response, will the fast-tract to accelerate the fight against HIV and to end the AIDS epidemic by 20130 become a reality.

Recommendations:

  •  Reduce incarceration for key populations, especially people who inject drugs
  • Introduce and scale-up HIV prevention with Opioid Agonist Therapy, Needle Syringe programmes and Anti Retroviral therapy, including effective transitional programs post-release
  • Improve testing and treatment strategies (continuum of care) for HIV, HCV and TB.
  • Eliminate the gap between prison and community treatment and prevention services, including structural impediments for service delivery and continuity.
  • Integrate services given the high rate of medical and psychiatric co-morbidity.

The Standard Minimum Rules for the Treatment of Prisoners were first adopted in 1957, and in 2015 were revised and adopted as the Nelson Mandela Rules with eight substantive areas revised. By the UN General Assembly in December 2015.   

UN Standards on Treatments of Prisoners -- Mandela Rules (2015)

·         Prisoners must be managed in a manner to respect and protect the human rights and dignity of prisoners. 

·         Prison should be viewed as a place for preparation for reintegration of prisoners and society - minimise differences with outside world. 

Adequate space, food, sanitation.

No discrimination.

Health care to meet prisoner's needs throughout detention and linkage to public health.

Monitoring and accountability.

 

“It is said that no one truly knows a nation until one has been inside it jails.  A nation should not be judged by how it treats it highest citizens, but its lowest ones.”…………Nelson Mandela

Tagged in: AIDS2016

A rather late (18:30-20:30) but very interesting session.

Richardo Garcia-Lema presented the findings of his study in macaques which investigated several different intermittent TDF/FTC schedules to cover teh vaginal exposure to SIV, including: two pills within 24 hours before and after exposure each; one pill 24 hours before and one pill 2-3 hours after exposure; one pill 2-3 hours before and one pill 24 hours after exposure; two pills each time within 24 hours before and 24 hours after exposure. While all schedules were protective, the latter was most effective. The study highlighted the importance of post-exposure dosing, which has to be taken as soon as possible after exposure. 

Jean-Michel Molina summarized the key findings of the French-Canadian IPERGAY study:

  • HIV incidence was above 6 per 100 person-years and was twice higher than expected;
  • the risk of HIV was reduced by 86%, which is some of the highest (if not the highest) levels of protection from HIV observed in clinical trials;
  • risk was reduced due to intermittent, not daily PrEP;
  • intermittent PrEP is highly effective in gay men who are frequently exposed to HIV, and 
  • intermittent dosing includes an inherent recommendation of how to start and stop PrEP (two pills before first exposure, one pill daily during ongoing exposures and one pill per day for two days after the last exposure). On that point, Bob Grant commented that he still struggles with the recommendation (or rather the lack of one) on how to start and stop daily PrEP.

Intermittent PrEP is now recommended in France, UK, Europe, and is up to be recommended in the new Canadian guidelines (which are being finalized now).

 

The discussion returned quite a few times to the importance of adherence to daily PrEP or strategic use of intermittent PrEP (strategic use seems to appear a new term to indicate correct use of intermittent PrEP). 

Another important point in the discussion was that appropriately conducted information and education of patients at the start of PrEP results in better adherence to PrEP and unilaterally in better prevention outcomes. 

 

 

 

 

Tagged in: AIDS2016

John Brooks from the CDC in Atlanta provided an update on the HIV outbreak first identified in Indiana in December 2014. I reported on his first update from the IAS Conference in Vancouver in July last year.

A couple of things are very noteworthy from these presentations. The response to the outbreak was dramatic, all be it very costly, and effective. What is hugely upsetting is that it could have been prevented with a good public health approach to HIV in the first instance.

A small cluster of HIV infections were identified in a rural county in Indiana. Case follow-up and contact tracing has identified 188 infections. The vast majority of these were identified in the first half of last year with only 11 being identified more recently, and of those the majority had been approached but declined testing previously.

A lot of features made this a perfect storm: no needle and syringe program; high levels of injecting (4 - 15 times daily and sharing with 1 - 6 partners) the reason for this is that the main drug injected was oxymorphone, which sells on the street for up to $140 per tablet, so people inject small doses, regularly to manage withdrawal. High levels of intergenerational sharing, with the belief that this was protective.

The county has the lowest socio-economic profile. Access to health care was limited, many people were uninsured and not registered for social security, unlicensed, not working and did not have common documents such as birth certificates.

This is an excellent presentation which show how a significant epidemic can occur in close knit community with limited access to resources, education and information. Viral sequencing has demonstrated that these were very recent infections and all linked. 

The plenary

http://www.croiwebcasts.org/console/player/29695?mediaType=podiumVideo&

and all of the slides amd MP3 are available at http://www.croiwebcasts.org/y/2016/25?link=nav&linkc=date

There was an HCV positive rate of >90%. But the HCV, unlike the HIV was well established in the cohort, coming from multiple sources over many years. A complementary presentation by Sumathi Ramachandran, Networks of HCV Transmissions Among Persons Who Inject Drugs: Indiana, 2015  looks at hepattiis C infection in this community can be found at http://www.croiwebcasts.org/console/player/29742?mediaType=slideVideo& 

There has been considerable discussion about the potential for outbreaks in rural and remote communities in Australia. This experience is one which should be viewed by all involved in the public health response to HIV and by all those involved in policy making which impacts public health.

 
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