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.

Testing and Treatment

Mycoplasma Genitalium: Should we look and how can we treat it?

Dr. Tim Read

Mycoplasma Genitalium (MG) is the bug that has all of a sudden made day-to-day testing and treatment in a sexual health service complicated.  No longer can we just test the heterosexuals for chlamydia and everyone else for everything else - MG has raised questions and have had sexual health clinicians almost at logger-heads with what to do about it - who to test, asymptomatic or only symptomatic; what to do if found - straight treatment or reduce the bacterial load first and then treat specifically?

Dr Read showed information from Melbourne Sexual Health regarding the prevalence of infection in both asymptomatic and symptomatic men who have sex with men.  He concluded that if we look we will find!  But is is not clear how a MG in an asymptomatic man might affect that man or his partners. 

It is known that MG causes the same spectrum of infection as Chlamydia and it is known that untreated CT is thought to be problematic in both men and women due to the inflammation it causes - leading to possible scaring, infertility and pelvic infection etc.  But not enough is known about the long term sequelae of MG.

Treatment is complex and MSHS is using long course treatment (doxy/azithro or doxy/moxi) -   However they have also utilised 'resistance-guided' therapy using a PCR  test that not only detects MG but informs the clinician if that particular sample has macrolide resistance. (2/3 of samples in this research were macrolide resistance).  Using this technique they had a 90% cure rate using doxy to lower the bacterial load.

The recommendation he gives for MG are as follows -

Treat NGU with doxy pending MG test

consider reducing the azithro when coinfection with MG likely

base therapy on known of likely macrolide resistance

do not screen asymptomatic people for MG

need more data on prevelence in heterosexuals.

 

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Lymphogranuloma Venereum in the era of PrEP: are we heading for another epidemic?

Professor David Templeton. Normal 0 false false false MicrosoftInternetExplorer4

Professor Templeton presented a paper on the transmission dynamics of rectal LGV.  He gave information regarding the prevalence of infection being significantly more prevalent in gay and bisexual men (GBM) and even more significantly higher in HIV positive men.  He posed the question ‘Is it all behaviour or does immunodeficiency play a role?’

The research he had looked at suggested a differing theory of CT transmission (including the LGV serovars) this being the role of ano-oral transmission from gut reservoirs of infection passed through faecal-oral contamination.  In comparison to the thinking that it might be past via rimming and fisting. CT can be transmitted from the urethra of men into the throat of their partners, it then is carried through the gut (the gut with it’s down-regulation of inflammatory responses allows CT to survive), it then infects the rectal mucosa and sets up a persisting infection (that then might lead to symptomatic or asymptomatic carriage of LGV or CT.)

 

This has been suggested by several authors that I found in the reference list of the paper Professor Templeton was quoting –  The Enigma of Lymphogranuloma Venereum Spread in Men Who Have Sex With Men: Does Ano-Oral Transmission Play  a Role? de Vries, Sexually Transmitted Diseases 43, 7, 2016.  Some of the work is based on animal models – where animal CT and ‘LGV – like’ infections occur and persist in the GIT and are not cleared with macrolide treatments.  

There are some studies by one author who looked at  infection in babies at risk of CT infection at birth and how long it took for the infection to get to the anus of the baby and the vagina of the baby girls – postulating that the infection had to travel through the gut and then through feacal contamination enter the vagina. (for further information read  Hidden in Plain Sight: Chlamydial Gastrointestinal Infection and Its Relevance to Persistence in Human Genital Infection Rank & Yeruva, Infection and Immunity 2014 ;82 :4,  1362–1371.

In practice this has implications for testing and treatment as rectal CT and LGV are vastly different to uro-genital infection.  Therefore non-sexual health clinicians must ask about sexual practices (or just test every orifice in both men and women), GBM with proctitis or procto-colitis who get sent to Gastro-enterologist must have an anal swab first (symptomatic LGV can present as Crohns Disease for example and be missed) and any GBM with ano-rectal CT infection should have their sample sent for LGV serovar testing.  The research is suggesting that heterosexual transmission of LGV is very unusual however continuing vigilance and surveillance is needed to detect shifts in infection dynamics within our community.

Rates of Transmitted Drug Resistant Mutations in Newly Diagnoses HIV in NSW 2004-2016

Angie Pinto

This was interesting as the results showed more transmitted HIV drug resistant mutations  found in the rural and regional areas of NSW, in younger people, with <10% mutations found.  Although Ms Pinto suggested this could not be generalised to populations outside of the NSW research areas I think it highlighted the need for vigilance in remote, rural and regional Australia.

Fortunately living in a rich nation we are able to request HIV genotyping tests with each newly diagnosed HIV case  and this is usual practice. It is also very fortunate that there were no resistance mutations found in Tenofovir and only a tiny number against Emtricitabine  -  which of course are the 2 drugs used in PrEP.

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2.  Tuesday 7th

Labiaplasty: factors leading to increased requests among women from a survey of GP experience.

Magdalena Simonis

This talk was really very sad in many respects.  In my own practice I have experience of young women (as young as 15yrs) wanting to have their labia modified, often without ever seeing other labia to know how normal they are.  With the adolescent body changing so dramatically at 15 it isn’t hard to understand the horror some young women must feel when they notice the changes to their genitals-  looks, skin, hair, discharge etc. Luckily these concerns can be addressed and reduce the health anxieties of the client with correct information.  Unfortunately, many young women in our society are not given any information about this – and certainly in my practice many women have no idea that they need a vaginal discharge every day for example.

Some of the concerns raised included the lack of knowledge of how these surgeries when done are going to affect the women as she ages – with atrophying of the labia during menopause.  There is now knowledge however on how it may cause considerable distress and discomfort if the surgery is not performed correctly or if there is some complication – bleeding, infection and pain etc. 

Some of the long-term effects may be hypersensitivity – especially if the clitoral hood is shortened to expose the clitoral bud. When even the wearing of clothes may be painful. There may be decreased sexual sensitivity if the edges of the labia minora are removed (there is a technique where the body of the labia is ‘wedge-resected” to avoid the more sensitive edges of the labia.) 

This procedure is the 4th most common cosmetic surgery after the nose, liposuction and breast augmentation in Australia, the surgeon does not have to be a registered cosmetic surgeon and the client over 18 years does not have to have counseling or a cooling off period.  Women under the age of 18 have to have a 3-week cooling off period just in case they change their mind.

I have heard some arguments that this surgery is no different than having other parts of the body being modified  - the women's reasons for having their labia reduced is because of the physical look (aesthetics) or a functional concern but this talk that gave examples of the research around the psycosexual distress, relationship concerns and sexual assault that women have experienced when counselled. 

 

The Implications of HIVSTI on Sex Workers

Udesha Chandrasena - Policy Officer at Scarlet Alliance, Australian Sex Workers Association

This was an very interesting session focusing on the accessibility of "self-test" HIV test kits that are currently available online and that have been made available to people in rural areas of Australia. With the changes and increase in availability of technologies that will allow for fast results, with some accuracy, to determine someone's HIV status, Udesha presented that this has potential to impact positively and negatively on sex workers.

The ability to have people attend tests at non-clinical locations can have great potential benefit in allowing for confidential testing in a private setting but can also have potential for significant issues.

Sex workers in Australia have been shown across Australia to have lower rates of HIV than the general population and also when compared to rates of sex workers overseas. This has been made possible through strong peer group programs in Australia and can only be measured in this population as a success, something that should be recognised. However this is not new data and across Australia every state and territory has it's own legislation regarding sex workers and a persons HIV status. This has potential to impact this population at risk with emerging new technologies that laws may not be keeping up with.

The advent of technologies with the ability to test a person on site or that need to be sent elsewhere for results may lead to an increase in the number of people tested but could also open workers up to potentially dangerous practices in their workplace. This could lead to bullying within brothels to be tested, to have workers be coerced by other workers, clients or brothel owners or managers to test in their presence. This has potential to impact on the workers safety, ability to work or force people to change practices or even be stopped from working. With differences between testing kits, techniques and potential technical issues with these technologies, this could lead to issues with false negative outcomes which would be managed differently in a clinical setting or with more "traditional" testing techniques.

Udesha argues that the current high rates of voluntary testing among the sex worker population be acknowledged and that changes to legislation across the country be made to ensure safety for workers.

In conclusion, there is potential for an increase in the numbers and scope of testing, however this can also negatively impact on sex workers. Changes in legislation across Australia is necessary to accompany this new technology.

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