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

Challenging start to the day with two interesting trainee case presentations with Sian Goddard presenting two linked cases of syphilis in a mother and daughter and a reminder to screen at risk immigrants; and Vinita Rane presenting a case of HSV penile ulceration in a HIV positive patient, with other confounding STIs, that was successfully treated with imiquimod. 

Congratulations to both on these excellent presentations.

Tagged in: HIVAIDS2015
PrEP Community Forum (aka Are you PrEPing for the future?)

What a privilege to attend this forum which featured amongst others Dr Robert Grant, named one of Time magazine’s most influential people in 2012 for being the father of “treatment as prevention.” Dr Grant highlighted the observation that PrEP use in San Francisco had reached a positive tipping point in the last few years, with increasing use of PrEP. How have they come to this point?

It's been driven by:
1) PrEP research and demonstration projects being run in San Francisco
2) The FDA approval for Truvada use in PrEP, and
3) Word of mouth and the use of social media

Dr Grant also reiterated that by using an intention to treat analysis, PrEP is efficacious - the analysis shows that in order to prevent 1 HIV infection, 13 to 18 people were required to be treated. The recommendation for PrEP is for daily dosing although the data shows that if users were taking PrEP 4 times or more per week, the benefits were maximised. Daily dosing provides for a high level of protection and is forgiving of the occasional missed dose. The exciting takeaway message I took was that currently, there are Phase 2 Trials in long acting injectable PrEP, which may come to fruition around 2020.

Dr Darren Russell spoke about PrEP in Australia and the current 'lay of the land'. Importantly, he announced that the HIV Foundation Queensland was in planning to roll out an affordable access program for low-income individuals via the Foundation, to counter the social and ethical inequities of access to PrEP in Queensland. Dr Russell also 'hypothesised' that Truvada for PrEP may obtain TGA approval in the first quarter of 2016 and hopefully PBS approval in the latter half of 2017 (all going well). Watch this space!

Most importantly, this forum highlighted the social science and personal impacts of PrEP - it's ability to mitigate the fear of HIV, the empowerment of users, the circumvention of condom difficulties to prevent HIV infection. We heard both from Chris Williams an early adopter and PrEP advocate and Dr Fiona Bisshop, a PrEP prescriber at Holdsworth House Medical Brisbane.

The final word? If you are not PrEP'd for the future, you better get with the program.

Posted by on in Public Health and Prevention

We kickstarted the conference with an update on potential vaccines for STIs by Prof Ian Frazer, the co-founder of the HPV vaccine.  He gave a 'passing grade' on his STD vaccine score card for vaccines against Hepatitis B and HPV vaccinations but major innovation is needed for vaccines against treponema pallidum, neisseria gonorrhea, mycoplasma genitalium, trichomonas vaginalis and H. ducreyi.  There was some sad news and exciting news.

The sad news was that there was a marked disparity between rollout of HPV vaccine programs and cervical cancer prevalence.  So, the countries that have the highest rates of cervical cancer (mostly on the African continent and South Asia) have no HPV vaccine programs currently.

The exciting part of his talk was around his work on a vaccine against Herpes Simplex Virus.  Whilst a previous paper in NEJM 2012 Jan 5:366 (1):34-43 showed some protection in HSV 1-2 uninfected women against HSV-1,  the protection conferred was not significant enough to warrant further development of that form of herpes vaccine.  However, Ian Frazer's group is now looking at a herpes vaccine using newer technologies (now in phase 2 trials) that may show greater promise.  Watch this space!

 

Jason Ong.

Tagged in: HIVAIDS2015
How Drug Policy Should Respond to the HIV Epidemic

Walking around Vancouver you can't help noticing the shops selling medicinal cannabis - the big cartoon weed pictures are so obvious!  So it was interesting to hear about the response to the IVDU problem here, and in yesterday's plenary Dr Evan Wood gave a summary of the main issues and how local authorities have worked to address them.

Dr Wood is a Professor of Medicine with an interest in HIV and drug addiction. He has been researching the impact of medically supervised safer injecting sites in reducing drug-related harm while increasing access to detox services for drug users. His research was the first to clearly demonstrate the positive impacts of safer injecting facilities for injecting drug users in Canada. This research has been instrumental in the development and continuation of Insite, a supervised injecting site in Vancouver that has saved many lives.  Dr. Wood pointed out that stigmatization of drug addiction is a major barrier, and he has been a voice for evidence based policies rather than ones based on negative perceptions of drug use.


He described the 4 Pillar approach to tackling drug use:

  1. Prevention
  2. Treatment
  3. Enforcement
  4. Harm Reduction

Vancouver had an explosion in HIV cases amongst its IVDU population in the 1990's, which at its height saw a fatal overdose occurring every day.  This prompted the city authorities to use a new approach.

The strategies employed included:

  • sterile needle provision
  • supervised safer injecting facilities (which prevents needle sharing)
  • methadone programs and other OSTs
  • treatment as prevention

Unfortunately, the 4 Pillars philosophy is not shared by the Canadian federal government, and a quick google search reveals that there is still much debate over the issue.  This is despite Dr Wood's claims that new HIV diagnoses in the IVDU community in Vancouver have dropped by 90% since the actions were implemented.

In stark contrast, at today's plenary I caught the last 10 minutes of the overview of the HIV situation in the Russian Federation, Eastern Europe and Central Asia, and was dismayed to hear that the situation there with respect to HIV in the IVDU population is very serious, largely driven by unsafe injecting although heterosexual transmission is also increasing. 

There are very few structured and recognized civil society and community-based organizations in most countries in the region.

The Russian Federation has some of the world's highest incarceration rates, with prisoners often waiting in overcrowded jails for months before trial.  Unsafe injection use, corrupt prison staff and high rates of unsafe sex and TB prevail.

Drug policies rely heavily on prohibition law enforcement, and methadone is illegal.

It is hard to see how a focused approach to the problem can be achieved under such circumstances.

 

 

 

 

 

Tagged in: IAS2015

 

 

Greetings  from Vancouver where the weather ( I am sorry to make you jealous) is absolutely gorgeous.

 

An interesting  satellite session on Rectal Microbicides, presented today by the Microbial Trials Network (MTN). Despite the proven effectiveness of PrEP there is still enthusiasm from sectors of the community for continued development of this alternative prevention tool. Not all MSM will be able to or want to take daily Tenofovir/FTC. Anal sex is also widely practiced by heterosexual couples particularly in Africa so there is much potential for use by these couples for the same reasons  vaginal microbicides are important.

 

The first ever Phase II trial to assess safety and acceptability of a rectal microbicide, MTN017 has just  been completed and was discussed by protocol chair Dr  Ross Cranston of University of Pittsburgh. Subjects were MSM and transgender females in multiple global locations

 

There were three treatment arms –

 

1.daily oral TDF/FTC

 

2.daily rectal reduced glycerin (RG)  tenofovir 1% gel (Phase 1 studies of ordinary tenofovir 1% gel found that when applied rectally it was associated with siginificant bloating, abdominal pain and diarrhoea. A reduced glycerin preparation was made which caused less osmosis in the rectum)

 

 or

 

3. RG TFV 1% gel used only before and after sex.

 

 Alll participants trialled all three methods and reported back on likelihood of ongoing use and ease of use. Data will likely be published in Feb 2016.

 

Several interesting ethical questions about the conduct of rectal microbicide trials  were raised by  Dr Ndebele of Medical Research Council of Zimbabwe. Most importantly, now that PrEP has proven to be so effective, should it also be provided as part of the comprehensive prevention package to trial participants, along with condoms and counselling regarding safe sex ?

 

I tend to think it should, as did most of the rest  of the audience, given UNAIDS Guidelines on ethical standards for HIV Prevention trials state “ participants should be offered state of the art risk reduction methods as they become available.”

 

This obviously raises many issues such as

 

- impact of cost

 

- the ethics of providing PrEP to participants in countries where there is little chance it will be available anytime soon and then withdrawing their access at the end of study and

 

- if uptake of PrEP were high amongst participants it would seem unlikely that you would be able to assess the efficacy of the microbicide.So what’s the point !

 

Dr Ian Mc Gowan another lead investigator discussed likely future directions for the MTN. This includes attempting to find a gel which could be used as a lube rather than inserted with the unpopular applicator currently used. The possibly of developing an alternative drug dapavirine which is more potent than tenofovir was also discussed.

 

The session wrapped up with a panel discussion between community representatives from the trial sites in the US, Canada and South Africa.

 

 They discussed

 

- how important  the development of rectal microbicides was for them as an alternative method for HIV prevention

 

- the importance of getting the product right so that it was an acceptable alternative

 

-the need for researchers to engage and invest in the community so that community members can participate meaningfully in trials  and

 

-the need for a gel that could be used both vaginally and rectally, being  useful for women for both types of sex and also to avoid the stigma for MSM in many countries when buying a product that idenitfied them as being engaged in anal sex.

 

It will be interesting to see how the MTN  goes. There are significant challenges and probably some sectors who will be sceptical of the need for rectal microbicides. However the more choices people have the better I think !

 

Slides for some of these presentations available on the IAS2015 website by clicking on the session on the Programme at a Glance.

 

 

 

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