Good morning from the 2017 HIV/STI Conference in Rio De Janeiro. There may be a cross over in some topics with other ASHM bloggers but over the course of the congress we will be blogging about different items.

This morning commenced with WHO treatment updates and guidelines, which had not been updated since 2003. The WHO updated guidelines and their objectives focused on ensuring they have international guidelines for the effective treatment of Neisseria Gonorrhoea, Chlamydia Trachomatis and Syphilis.

The majority of all treatment guidelines have already been adopted by Australian STI Management guidelines (STIPU) and are in place, but the key points taken will be outlined below.

* Neisseria Gonorrhoea (Assoc. Prof. Magnus Unemo - Director Swedish Reference Lab) - Dual Therapy (Ceftriaxone 250mg IMI with Azithromycin 1g Oral) recommended in all cases (Ano-Rectal, Oropharyngeal and Genital), unless resistance to Azithromycin is known, then single therapy with Ceftriaxone 250mg or Cefitixime 400mg can be used but again this only in specific cases and specialist advise should be obtained.
NB: STIPU do recommend 500mg Ceftriaxone IMI as do a number of other clinics worldwide. 

- Reinfection is treated again with dual therapy, but consideration could be given to treat with 500mg Ceftriaxone IMI with 2g Azithromycin Orally.

* Chlamydia Trachomatis (Nicola Low - University of Bern)

Guidelines were again similar to what STIPU guidelines in Australia recommend with a strong enforcement around Doxycycline versus Azithromycin in Ano-Rectal cases.

- 1g Azithromycin oral for Uncomplicated genital infections or Doxycycline 100mg Oral twice daily as alertantive treatment.

- Ano Rectal infections, there was a important point about ensuring Doxycycline 100mg BD for 7 days was used as first line treatment, and that Azithromcyin not be used as a treatment option. 

- For LGV, Doxycycline 100mg BD for 21 days is now recommended treatment versus the previous 14 x day treatment. 

- An important change from the 2003 guidelines was that Erythromycin was considered first line treatment in pregnancy, but now Azithromycin is the recommended treatment for women with a Chalmydia infection during pregnancy.

It should also be noted that Nicola Low mentioned there was not enough evidence for Azitrhomycin extra dosing to be used to treat Ano-Rectal Chlamydia as previously done for patients who might have had issues with Doxycline dosing adherence.

Treponema Pallidum (Syphilis) - Dr. Francis Ndowa (Zimbabwe).

Australian STIPU guidelines already reflect current guidelines.

- Early Syphilis -  2.4million units (1.8g) Benazthine Penicillin IMI as a single dose is still recommended as first line treatment or Doxycyclinne oral 100mg BD for 14 x days if there is a Penicillin allergy. 
(NB: Numerous other alternatives given, but not enough information was transcribed to write about)

- Late Syhpilis (>2 years) - 1.8g Benzathine Penicillin IMI as three doses spilt into 3 x weeks (i.e.: Every seven days), which is current to Australian guidelines. 

Genital Herpes Simplex Virus (HSV) - Prof. David Lewis - (Australia).

19.2 million new HSV2 diagnoses in 2012 for people aged 15-49 (11.3% Global prevalence)

6 x recomendations which show commence treatment straight away on first initial episode. Evidence showed a reduction in symptoms 2-4 days less than placebo and HSV shedding in 9.2 days
NB: See Brett Hadlow's blog for information around medication dosage recommendations).

For cases under four occurrences a year, treatment again is recommended with a 2.5 day reduction in viral shedding.

For cases over four reoccurrences, repressive therapy is recommended over suppressive and a twice daily dose of Acyclovir (400mg) or 500mg Valaciclovir once daily. Evidence showed less frequent HSV occurrence, and reduced shedding.

Overall it was good to see Australia is working within the WHO guidelines to combat STI prevention and ensure appropriate treatment.

For current Australian STI Guidelines, please see http://www.sti.guidelines.org.au

Photo 1: Blogging in my hotel room with Brett Hadlow looking over Barra Da Tijuca Beach.

This morning saw the kick off of the STI and HIV World Congress in Rio de Janeiro Brazil.

First off this morning was the 2016 WHO Treatment guidelines - last updated in 2003.

Noting that the new guidelines will be released in 3 stages.

(A.Prof, Director) Magnus Unemo of Swedish Reference Laboratory

Neisseria Gonorrhoea:

Treatment recommendations for Dual therapy over single therapy.

Ano-rectal and UI-

- Ceftriaxone 250mg and 1G Azithromycin 

- Cefixime 400mg PO and 1G Azithromycin.

Oral N.Gonorrhoea-

- Ceftriaxone 250mg and 1G Azithromycin.

- Cefixime 400mg PO and 1G Azithromycin.

It's of importance that currently in Australian Guidelines 500mg of Ceftriaxone is recommended and the WHO recommend 500mg in it's 2nd line treatment when 1st line therapy has suspected treatment failure.

Representitives from the UK and Europe also stated that are currently using 500mg as first line therapy due to high prevalence of resistance.

Dr Nicola Low (University of Bern)

Chlamydia trachomatis 

Take home message- changes in guidelines

- Use of Doxycycline over Azithromycin for Ano-rectal infection.

- 100mg Doxycycline BD for 7 days.

LGV - Treat with Doxycycline 100mg BD for 21 days - was 14 days in previous guidelines. 

Dr Francis Ndowa (Zimbabwe, WHO consultant)

Syphilis

Primary, Secondary and Early latent (2 years or less)

Treatment is with (2.4 million units) 1.8g Benzethine Penicillin IMI Single dose.

Alternate Treatment - Procaine 1.2 IU IMI Daily for 10- 14 days.

Late Syphilis (more than 2 years)

Treatment is 2.4 Million units Benzethine Penicillin IMI one dose one week apart for 3 consecutive weeks.

In penicillin Allergy - 100MG Doxycycline BD for 30 days.

Dr David Lewis (Sydney, Australia)

HSV

19.2 Million new HSV infections in 15 - 49 year olds world wide in 2012.

Recommendation 1 - 1st Episode of HSV infection - treat.

Recommendation 2 - Treatment recommendation Use Aciclovir over Valciclovir or famciclovir.

Dosage 400mg TDS for 10 days.

Recommendation 3 and 4 - Recurrent symptoms treat within 24 hours of symptoms or prodromal phase with Aciclovir 400mg PO TDS for 5 days, 800mg BD for 5 days or 800mg TDS for 2 days

Valciclovir 500mg PO BD for 3 days.

Recommendation 5 - For recurrences of more than 4 per year consider suppressive therapy for 1 year and then reassess. Aciclovir 400mg BD for 1 year.

Dr Manica Balasegaram (Global Antibiotic Research and Development Partnership, GARDP)

Spoke about the development of new treatments for STIs and in particular showed a snap shot of a road map for development of new treatments for N.Gonorrhoea with the main goal of new treatment by 2023.

Main goals of accelerating new agents to be used and investigating existing antibiotics that could be used in new combinations. It's exciting to see that we are looking to the future in regards to Antibiotic stewand ship and treatment of emerging resistance.

Magnet is a nurse and peer led Sexual Health service in San Francisco. It recently co-located with Strut (San Francisco AIDS Foundation) and a number of other organisations working in the sector. I was warmly welcomed by Joshua O’Neill (HIV Testing Services Manager) and Pierre Crouch (Nurse Director).

The clinic opens 6 days a week and provides the following services:

-    Free STI testing and treatment on site and in mobile units around the city. The mobile clinics occur 3-4 times/week and with a bacterial STI pick up rate of approximately 8-10%, they provide an invaluable service to those who do not access mainstream STI services. Rapid HIV and Hep C (Ab) testing are also offered. 

-  PEP is offered free of charge. 

         -   PrEP is provided to individuals through several sources. Depending on health insurance status, PrEP may be funded under an individual’s health care plan. For those with inadequate or no private health insurance, Magnet has health insurance navigators to assist the process. Like in Australia, a high proportion of individuals import PrEP via the internet. Magnet is also a part of a double blinded RCT of 5000 HIV negative MSM randomised to receive either Truvada or F/TAF as daily HIV PrEP. This trial is not being conducted in Australia. 

       - Under the Stonewall project offered by Strut, free individual or group counselling for support regarding drug or alcohol use. 

          - An art gallery and lounge aiming to promote the physical, mental and social well-being of gay men. 

          - Social events for a variety of groups including transgendered and African American MSM.

          - STI testing and access to emergency HIV medication, PrEP or PEP to those visiting from abroad (no charge for a one month supply)

 Take home messages from the visit:

 1.     Mobile STI screening units provide an excellent way to reach MSM who may not access traditional STI testing and treatment services. With an STI pick up rate 8-10%, they create an excellent opportunity not only to diagnose and treat bacterial STIs, but also to reduce the number of undiagnosed people living with HIV. The benefits to both the individual and the community are obvious. 

2.     Australian’s visiting who have misplaced their HAART or PrEP, or those who require PEP while away, are most welcome to attend the clinic and will be offered a free 4 week supply of medication. It’s worth knowing about this as many of our patients travel to San Francisco.  

3.     The staff have hosted a number of international visitors in recent years and they welcome the opportunity to show health professional services when visiting San Francisco.

A.Prof. James. WARD - Aboriginal Health Perspectives.

A Predicted divergence of what is happing in Aboriginal and Torres Straits Islanders community’s in relation to HIV and STI’s.

New diagnosis of HIV in remote communities due to young mobile population.

Risk Behaviours such as sharing NSP Equipment, with a background of increasing prevalence of STI’s.

 Failure to engage Treatment as Prevention (PrEP) as need to take other medication (pill burden) for multiple health conditions/comorbidity.

 10-24 years age group, increasing Chlamydia and Gonorrhoea -                                                                  This highlights the inequities and lack of access to care.

Hep C – mostly transmitted through injecting drug use (IDU).  

Hep C has increased 43 % in 2011 – 2015.  

It effects the youngest 15-24 years old.

Hep C has 8 times the incidence in Aboriginal people (than non-Aboriginal People).

Rural and Remote Communities – need more access to Aboriginal Primary healthcare for testing and treatment and treatment as prevention (PrEP).

HIV in Cairns, QLD – young Aboriginal & Torres Straits Islander men in 2014-2016 had 50 % increase in HIV. This also effects bi-sexual men and men that don't dentify as gay.

NO access to NSP. Difficulties in approach to NSP and harm minimisation.

(Treatment as Prevention) TASP.

Prof. Ward said that we could learn from Canada’s first nation’s people in Saskatchewan that have a background of unresolved grief & intergenerational trauma. 

Increased of IDU and STI’s = HIV !

We need to prevent an outbreak occurring in our rural and remote Aboriginal and Torres Strait Islander (ABSTI) Communities. Health services are already limited and they would also not be able to cope with a major outbreak occurs. This would devastating to these communities.

ABSTI – vulnerability of population.

Need to increase the workforce in meaning work and career options

Need timely surveillance data, to be able to respond quickly    

Medicare to cover costs

Need to advocate ‘outside and ‘raise our voices’ (to Governments and the Australian people to increase awareness and be able to act/prevent). Especially non-Aboriginal People need to stand up and raise their voices about concerns and issues of our ABSTI People.

Increase the current low testing rates for HIV.                                                                                                                                                             Use a diversity/combination of strategies include - strengthen Aboriginal and cultural appropriate Primary care.

 Currently on 32% of people with STI’s are offered HIV Test. This needs to be offered 100%.

 Community itself needs to be interested and engaged.

Two presentations. The first looked at the impact Lay Health Workers can make on male and female HIV transmission, contraception and ART take up in South Africa. The second looked at the effected of decentralising testing in Myanmar.

Low HIV Incidence amongst Pregnant and Post partum Women Receiving a Lay Health Worker HIV Prevention Intervention in South Africa.

Background

Each year 1 million woman in South Africa become pregnant. Of those 30% is HIV positive.

Study

Health Workers provide information, education and counselling to male partners. They also education on multiple partners, mental health, alcohol use, provide condoms as well as linking care for those found to be HIV positive. They offered circumcision for men HIV negative and referred them accordingly, as well as symptom screening of STI’s.

Outcome

There was a huge decrease in people needing treatment within the group, verses the background South African population.  Maternal HIV incidences 73-86% lower than previous studies. Community based HIV prevention was effective, and Health Workers were found to be highly effective.

_____________________________________________________________

High HIV Positivity amongst other Vulnerable Populations Reached Through Decentralized HIV Testing and Counselling in Myanmar.

I found this presentation interesting, as it demonstrated how taking the test to the people is more effective than having the people come to the test. This will change my practice, as instead of providing information on where people can have a HIV test, I will investigate the possibility of having the test ready to administer to my patients.

Introduction

224,794 PLWHA in Myanmar live with HIV, which equates to 0.6% of the population. The key populations are People Who Inject Drugs, female sex workers and men who have sex with men. However HIV appears in other population groups, which are not being well serviced by the centralised testing program.

In 2014 HIV testing was decentralised. Since then, there has been a steady increase in testing. The number of people diagnosed with HIV steady decreased.

Results

There are high rates of stigma and discrimination towards PLWHA. High rates of diagnosis have been detected in miners, boarder regions, migrant works and mobile populations i.e. truck drivers.

Tailored services need to be developed to cater for the mobile population and increase access to testing for gold/jade miners.