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

An important group of presentations today on STIs, a somewhat neglected area of discussion in HIV, despite evidence that people with higher rates of STIs are at increased risk of HIV and vice versa.

 

First presenter was Darren Russell from Australia presenting some background on the epidemiology of STIs.  First and foremost, the point was made that, if you do not test for it, you will not find it and then you cannot treat it (much like the first 90 with HIV!)  and that in contrast to HIV, testing, reporting and surveillance of STIs is inconsistent throughout the world, making STIs the “poor cousins“ of HIV. Given the international nature of the conference, epidemiological data from around the world was presented for STIs.  One slide demonstrated that in the early 20th century, as many people died from syphilis as did from HIV/AIDS at the height of the epidemic in the USA.  The incidence of syphilis from late last decade throughout the USA, Canada, Germany, Sweden, France, The United Kingdom and Australia was noted to have risen significantly in all countries and a special mention was made of the syphilis epidemic in Aboriginal and Torres Strait Islanders, a group in which we must try to do better if we are to close the gap.  This presentation ended on a high note with a success – the roll out of the HPV vaccine and the dramatic decrease of genital warts in vaccinated Australian women and eventually men.  I thought that ending on this information really served to demonstrate to the sexual health community what is really needed to stop epidemics – vaccine development.

 

Next Presenter was Scott McLelland from the United States who presented on STIs and susceptibility to infection.  We have known for some time that STIs place people at risk of HIV and vice versa but elucidating exact mechanisms has been challenging and interventions have not been as successful as previously hypothesised.  Yet more recent data has demonstrated significantly increased risk of HIV acquisition with HSV2, vaginal dysbiosis (bacterial vaginosis) and HPV due to the immune response.  For example, the site of HSV lesions has been shown to have high numbers of CD4 T cells and dendritic cells as does HPV infected mucosa, providing increased target cells for HIV virus.  How we use this information as a basis for further research, treatment and ultimately health policy remains to be seen.

 

Next was Connie Celum, also from the United States who presented on STIs in the era of TasP and PrEP.  One of the first and very important points made was that there is no evidence to indicate decreased efficacy of PrEP in users who have an STI – demonstrated in both iPrEx and Partners PrEP studies.  One caveat was that bacterial vaginosis may impact the efficacy of topical vaginal tenofovir.  The possibility of PrEP programs actually leading to a long-term reduction in STIs was brought up and the role of regular STI screens as part of PrEP use as well as the potential for STI PEP using doxycycline, presented as part of the ipergay study at CROI in early 2017 were both put forward as mechanisms to reduce the burden of STIs in PrEP users.  The model of STI testing, treatment and follow up was also addressed with reference to the Dean Street Express clinic in London with changes in service delivery proving effective in testing and treating more people in a shorter space of time and as mentioned previously – if you don’t test for it, you can’t treat it!

 

Last but not least was Cecile Bebear from France who gave a presentation called “should we fear antibiotic resistance for STIs?” with a focus on 4 bacterial STIs – Chlamydia trachomatis, Neisseria gonorrhoea, Treponema pallidum and Mycoplasma genitalium. For Chlamydia trachomatis, the concern for antimicrobial resistance (AMR) is low with the organism remaining sensitive to tetracyclines, macrolides and quinolones and only very rare cases of macrolide resistance being reported, so as Chlamydia trachomatis remains the most common bacterial STI, it also remains very easy to treat. Neisseria gonorrhoea is the complete opposite however, with resistance to almost every agent ever used against it since about the 1930s.  First line treatment with combined antibiotics of two classes has held Neisseria gonorrhoea at bay, but for how long?  Extended cephalosporin resistance rates in this organism, where there is resistance monitoring range from 0.1% to 30 % in various parts of the world (up to 5% in Australia).  Azithromycin resistance ranges from 2-8% across the world, fluoroquinolone resistance 30%- 50% and tetracycline resistance more than 50%.  New treatments are in development pipelines but the ideal way to tackle this organism would be through a vaccine.  Syphilis remains relatively easy to treat with penicillin or doxycycline but does have a high prevalence of azithromycin resistance (84% in Australia).  Finally, the new kid on the block, somewhat of a problem child, Mycoplasma genitalium, tetracyclines demonstrate poor levels of eradication but no resistance characterised, macrolide resistance is widespread, between 43% and 63% in Australia and there is acquired resistance to the agreed upon second line treatment moxifloxacin, ranging from 4.5% in the UK to 47% in Japan.  Unfortunately, this problematic organism did not generate much discussion nor were potential third line agents for consensus discussed.  Certainly more research needs to be done in regards to this organism and consistent guidelines on management are required.

 

Tagged in: 2017 IAS Conference

Today I watched Catriona Bradshaw (Monash University, Melbourne) present on M.G.

WOW. Great presentation.

M.G Slow to grow and difficult to culture. 

Looking at resistance patterns around the world its very clear that over prescribing of Azithromycin has lead to macrolide resistance in M.G.

Looking at countries that have prescribed STAT Azithromycin for NGU and now looking at resistance profiles its very evident that we need to change our thinking and prescribing.

Catriona showed the resistance profiles of two countries side by side - Sweden and Norway. One Country having used Azithromycin in NGU treatment and the other having used Doxycyclin. Very different results.

It made me think of the landscape in Australia - and the different drugs being used in current guidelines. Which I might add are always evolving with new evidence.

Russia has a low prevalence of resistance - Its not used Azithromycin.

Countries that have used Azithromycin in NGU have had an increase in resistance from 10% to 40% in 10 years.

Widespread use of Azithromycin for STIs and Syndromes has led to high failure rates for M.G.

Some regions already leading the way - U.K. And Europe changing guidelines to recommend Doxycyclin.

We need to move towards testing that can perform resistance testing so treatment can be individualised.  This will shorten the duration of infection, reduce transmission of resistant strains and recurrent clinical presentations.

 

 

My focus today was on Mycoplasma Genitalium as it has been a topic of many discussions recently. 

Several presenters discussed this topic

Dr Catriona Bradshaw, Melbourne Sexual Health

Dr Jorgen Jensen, Statens Serum Institute, Copenhagen

Prof. Charlotte Gaydos, John  Hopkins Centre

Dr Lisa Manhart, University of Washington 

Mycoplasma Genitalium (MG) causes symptoms similar to C. Trachomatis & N. Gonorrhoea 

Sequelae in women include pelvic inflammatory disease, spontaneous abortion, preterm birth and infertility. 

Diagnosis is limited to NAAT as culture lacks sensitivity and takes a long time. It is however recommended that NAAT testing should include resistance assay.

First line treatment regimes have included azithromycin and doxycycline, individually or in varying combinations, but doxycycline has a low efficacy rate and macrolide resistance has developed after 20 years use of azithromycin for other STI's. 

Moxifloxacin has been used as second line treatment but the past 10 years has seen emerging failure rates in some countries with rates as high as 15% in Asia-Pacific regions. Recent warnings from FDA and Europe, high cost and side effects make this option unpopular.

Funding for testing and trials of new classes of antmicrobials include

* solithromycin

* lefamulin

* diafloxacin

* zoliflodacin

* gepotidasin

The emergence of dual class resistance to both macrolides and  quinolones means there is no highly effective class of antimicrobials currently available to treat  MG. 

Prof. Basil Donovan from the Kirby Institute Sydney in his discussion of treatment of chlamydia, advocates for alternatives to azithromycin. This concerns me, as my experience in a sexual health clinic is that poor compliance is a major factor for using single dose treatments. I hope that new antimicrobial treatments will include single dose. 

 

Posted by on in Testing and Treatment

I attended a lunch session sponsored by Cepheid regarding rapid STI diagnosis and use of point of care testing.

Working primarily in an Indigenous health setting in North Queensland I wanted to see whether a point of care testing model might be helpful with our patient cohort.

Dr Jeff Klausner started the session off presenting `Utility and applications of rapid, molecular STI testing in hard to reach populations´. The current STI statistics globally are quite staggering; over one million new STIs are acquired globally every day and each year there are 357 million new curable STIs ( CT/NG/TV and syphilis).  There is the rising risk of untreatable gonorrhoea, so much so that the WHO has listed NG as one of the top 3 infections that require immediate action. CDC reports demonstrate that STIS are increasing for the first time since 2006 and CDC STI guidelines indicate that treatment needs to be provided on the same day and directly observed.

Point of care STI testing clearly has demonstrated merit. For the patient it provides decreased anxiety and less patients are lost to follow-up. From a public health perspective there is decreased risk of forward transmission of infection, faster treatment for patients and their partners and decreased antimicrobial resistance. From an economic point of view there is scope to expand clinic capabilities, improve treatment costs and target individualized (rather than empiric) treatment. This was illustrated in the example of the Dean Street Express clinic in London. With the use of PoC testing there is quicker treatment, decreased waiting times and increased testing.

Dr Klausner discussed the rates of STIs in pregnancy and the negative consequences of STIs in pregnancy including miscarriage, stillbirth, preterm labour, low birth weights and increased MTCT of HIV. Currently only 13 countries in the world require routine chlamydia testing despite these known adverse outcomes. Point of care testing was trialled in 7 low-middle income countries and more than 2,200 pregnant women were screened for CT, NG and TV. The result of this trial showed high acceptability amongst patients and high treatment rates.

Dr Basil Donovan went on to discuss ´Implementing molecular POC testing in remote primary care in Australia´. Dr Donovan illustrated the difficulties of health care in remote Indigenous communities including the distance from laboratories, high mobility of the population, delays in time to treatment, high rates of PID and disseminated NG.

The Test, Treat and Go Trial was discussed (TTANGO). This was a cross over randomised controlled trial that compared traditional laboratory testing with point of care testing in a number of remote locations across Australia. Median time to treatment was 0 days for POC testing versus 7 days for laboratory testing. Patients reported that they liked getting their result on the same day, that they could be treated on the same day and that they didnt have to return for follow-up. The patient reported dislikes were that they didnt like ´waiting around´. Staff were also interviewed and expressed that they ´felt like a scientist at times´. The staff reported that the point of care tests were easy to use and interpret and they felt increased job satisfaction. Of course there are challenges to report which included high staff turnover in these communities, the need for ongoing public health surveillance and adapting clinical practice.

The session in my opinion was very useful and insightful and very relevant to my current clinical practice. At the particular indigenous health clinic I work at we have high rates of STIs, high rates of treating emperically and difficulty with follow-up. Point of care testing (if costs are appropriate) may be an option for our clinic to improve treatment rates and appropriate use of antimicrobials.

 

Posted by on in Testing and Treatment

Gwenda Hughes (National Centre for infectious Disease Surveillance and Control at Public Health, UK)

Spoke about some STIs that are neglected or under tested for. Primarily she spoke about Trichomoniasis. LGV and Enteric Infections.

TV - Seen very rarely in Australian population - but are we testing enough? A large poprtion of infections are asymptomatic. With a higher prevalence noticed in African and black women in the UK.

LGV - Endemic in Africa, Latin America and Asia. With small numbers seen in North America and Australia.

Recently there has been a resurregence in the reported cases in Europe with 25% of cases in the UK being asymptomatic and 50% of cases in Germany being asymptomatic. 

Germany also found that of the positive CT results in MSM 17% of rectal infections were LGV positive and 15% of throat infections were positive for LGV. I found the throat infections very interesting.

Entric Infections - Shigella, Hepatitis A, Giardia.

Outbreaks in MSM population in the UK - found to be higher in MSM that participated in Sex parties, Chem sex (slamming) and HIV+Ve practising CLAI. Are we missing these infections. We routinely test for Hepatitis A in our MSM population and we have great programs for free vaccination of Hepatits A. But shigella is not routinely tested for and requires testing of stool samples. 

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