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.

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Day 1 CROI 2017:

 

An overview of CROI this year for those may not have attended previously:

 

Today we were reminded that The Conference on Retroviruses and Opportunistic Infections (CROI) commenced in 1993 to provide a forum for basic scientists and clinical investigators to present their latest data, and to interact. The Conference has grown in size over the past 24 years and is currently capped at about 4,000 attendees. This year the 4,200 participants are from 90 countries, and 40% of abstracts were from outside the USA. One in five attendees are new to CROI, so if you have not attended before, try to get there next year (Boston 4-7 March 2018).  The opening sessions traditionally consist of: the Bernard Fields Lecture, named in tribute to the exemplary work of esteemed microbiologist and virologist Bernard Fields, and the N’Galy-Mann Lecture, named in honour of Drs Bosenge N’Galy and Jonathan Mann for their crucial pioneering work in HIV science in Africa. It is always a sad time to reflect on the untimely deaths of these two great men working in HIV/AIDS in the very early days of the epidemic. I will always remember Dr Mann’s extraordinary speeches in those early days – he was a great orator. 

 

This year the Bernard Fields Lecture was delivered by Jeffrey D. Lifson, from the Frederick National Laboratory for Cancer Research and focussed on the work done in HIV prevention and pathogenesis using nonhuman primate(NHP) models. Dr Lifson made the case that, with limitations, nonhuman primate models eg in macaque and sootey mangabey monkeys with SIV models, ‘have been able to recapitulate all the key aspects of human HIV infection in research systems that could provide important experimental advantages’ but that the viruses used in in NHP were not HIV.  He also discussed the issue of gut pathogenesis in HIV/SIV infection with the sequence of events:

 

·       Loss of CD4+ t-cells

 

·       Epithelial disruption

 

·       Microbial translocation (microbiome shifts)

 

·       Local and systemic immune activation/inflammation

 

·       Responses to inflammation Treg, TGF-B, LT fibrosis,

 

·       Not fully restored/reversed by cART.

 

A number of presentations at the conference will be on the changes in human gut microbiome with acute HIV infection, ARV therapy and elite controllers.

 

The N’Galy-Mann Lecture was delivered by James G. Hakim, University of Zimbabwe on the HIV/AIDS research in Zimbabwe which has included collaborative research with the ACTG in USA and the Kirby Institute in Australia.  The opening session concluded with a special CROI Foundation award to Oliver Mtukudzi, a wonderful musician and human rights activist from Zimbabwe.

 

  

 

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CROI 2017: Opening Session

Dr Susan Buchbinder opened CROI 2017 with a powerful statement rejecting the recently halted US Presidential edict restricting entry into the US from seven Muslim majority countries. Apart from the obvious human rights aspect of the ban, the major impact of the travel ban would be on the free exchange of scientific information. The statement was particularly meaningful given that Federal Judge James L. Robart who launched the temporary restraining order is from Seattle.

Bernard Fields Lecture

Dr Jeffrey Lifsom presented the Bernard Fields Lecture on insights into HIV prevention, pathogenesis and treatment from non-human primate (NHP) models. Dr Lifsom helped develop the highly sensitive quantitative assays for HIV and SIV that are currently used in research and management. Drawing on Dr Bernard Field's work, Dr Lifsom described how NHP models had contributed to the understanding of HIV with respect to:

  • Transmission: eg. how early distal SIV RNA found in mucosal transmission correlated to tissue changes found in HIV
  • Pathogenesis: eg. the discovery of the gastrointestinail system as a major site of CD4 T cell and viral replication for SIV infection, which was subsequently extended to HIV in humans. In particular, how epithelial disruptions resulted in immune activation and inflammation that was not fully reversed or restored by ART
  • Vaccines: eg. the use of a CMV vectored SIV vaccine to provide a persistent immune response, demonstrating that an unconventional response appears to result in enduring protection. This may lead to the promise for novel vaccines, including for other intracellular infections such as TB and malaria.
  • Treatment: eg. the use of injected TFV/PMPA in NHP models was critical in the decision to develop orally bioavailable TDF. More recent developments are the use of a highly effective long-acting triple drug regimen which will influence treatment strategies.
  • Viral Reservoirs: eg. The role of immune privileged B-cell follicles and clinically expanded T-cell clones with the persistence of SIV and HIV infections

Dr Lifsom concluded by saying that thoughtful selection of NHP models matched to the question of interest can provide experimental advantages and yield important insights.

N'Galy-Mann Lecture

Dr James Hakim, prominent researcher and clinician from Zimbabwe presented a fascinating insight into how his country turned around a devastating medical and socioeconomic epidemic to be one of the leading research areas in the world for HIV today.

In 1986 Zimbabwe had an HIV prevalence of 29%, with an incidence of 4.7%. This has been turned around to a prevalence today of around 14%, with an adult incidence of 0.48%. There has been a significant collaboration with international organisation to implement a robust research agenda and build capacity in the Zimbabwean health and research workforce. The initiatives of PEPFAR and NIC have invested significantly in sub-Saharan medical schools, to empower them with an improved qualify of education, leadership and research capability.

One of the most disturbing statistics that Dr Hakim presented was that Africa has 24% of the world's disease burden with only 3% of the world's health workforce. Ongoing support and collaboration is required to continue progress towards the UNAIDS 90-90-90 targets - noting that in 2016 Zimbabwe is tracking at 74.2/86.8/86.5 against those aspirational targets - a remarkable achievement given when the country started from some three decades earlier.

Special award

The delegation was treated to a performance by Mr Oliver Mtukudzi, a musician and human rights ambassador who has championed the cause of HIV/AIDS in Zimbabwe. He was given a special award for his contribution towards raising the awareness of HIV/AIDS, and trying to reduce the stigma of the disease through his music. In his words, "Art speaks to people's conscience"

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Day three Australian HIV/AIDs conference 2016  

 

Towards elimination:  parallels between HCV and HIV models of care – 

Joseph Doyle, specialist in infectious diseases and public health medicine.

 

KEY POINTS

•Australia has 230,000 cases of HCV, a relatively low prevalence. This consists mainly of PWID but also a      significant proportion who acquired HCV through sex, especially if HIV pos. 

•WHO 2020 targets aim for a 30% reduction in  new dx of HCV and a 10% reduction in deaths from HCV.

•To ensure success those at risk need access to frequent, regular testing to ensure early dx, with early dx leading to early connection to care. Australian guidelines recommend annual HCV testing for those at risk (or testing associated with a specific risk) and once ever testing for the rest of the population. 

•Testing programs need to be considered – as antibody/PCR testing take two visits, Genotype will hopefully be made redundant and liver disease test such as fibroscan – not required for people with APRI<. Rationalising testing reduces time required to treat. Rapid RNA and annual testing in PWID  - will help to meet WHO target. 

•Improvements in treatment have been due to highly effective treatment available on PBS (the near future will see a single pill regardless of genotype). Community prescribing (unique to Australia and supported by specialists), no disease stage restrictions and no need for fibroscan.

•Elimination is more likely if treatment is targeted to PWID/ MSM/ Overseas born (due to a small element of vertical transmission from more high prevalence countries). 

•Treatment of PWID has been shown to be effective/ safe/cost effective and can be given in conjunction with harm reduction strategies such as OST, NSP and peer support to increase the likely success of treatment and prevent reinfection.

•A scale up of treatment to 40/100 PWID p.a could halve HCV prevalence in 15 years and using injecting network data/bringing along injecting partners could reduce prevalence by 85% parallel to new dx HIV contact tracing .

•Other strategies include potential vaccines that even if only partially effective can still impact the epidemic in high prevalence area’s. 

•To achieve the mortality target those with advanced disease will need to be targeted, this can also be achieved by treating PWID due to new HCV cases prevented.

•In conclusion, to meet WHO targets of HCV elimination and reduced mortality testing and treatment will need to be targeted and include injecting networks. Rationalising tests and simplified effective treatment can go someway to achieving this goal. 

 

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The positives and negatives of porn: an overview of the evidence.

The focus is more around young people and heterosexual.

Average age to first see porn is age 13 for males, and age 16 for females.

Most men were watching porn at least weekly.

Gay porn contains a lot more condoms.

Men receiving oral sex much more commonly than women.

Young people report learning about sex through pornography.

Learning about sex was particularly reported by same-sex attracted individuals.

Not wearing condoms and STIs are linked to pornography use.

Women watching porn is often seen as a good thing for a relationship.

There are reports of pornography addiction but there is little evidence to support this, relying mainly on sporadic case reports.

People who are violent are likely to both perform violence and watch violence in pornography.

Body image - little research here to support anything.

Most research is poor quality, out of date, doesn’t look for causation.

Most look for harms, and if you don’t look for a benefit you’re not likely to find one.

Some people feel pressured into doing what they see in porn.

Most people in the industry will get one or two infections per month.

Same-sex porn can be limiting in terms of the stereotypes presented.

What benefits are there to porn?

A partner with a higher sex drive can have an escape, rather than pestering the other partner or seeking sex elsewhere.

Sex acts can be normalised, allowing them to feel comfortable with doing them.

Technically porn is not legal in Australia (hosting cannot be on Australian servers)

It is not legal under the age of 18 years.

Filtering can be applied by governments, parents, internet service providers, but there are problems with censorship - sexual health sites tend to get blocked for example, and other people’s opinions determine what you can watch.

If we had good sex education maybe people might seek out pornography less often.

It’s going to be around for some time, and everyone has an opinion about it.

Perhaps we need some way of being able to talk about it.

Dr Cindy Liu from George  Washington University presented interesting findings on the vaginal microbiome today. 

 The term ‘dysbiosis’ refers to an ecological imbalance in the microbiome that impairs health. It moves away from the classic concept of infectious disease as being caused by a single pathogen, and moves toward the appreciation of disease as disruption to a complex, dynamic ecosystem. Disruptions might be the loss of ‘good’ bacteria, dominance of ‘bad bacteria’, but the imbalance leads to events that impair function, or induce inflammation. 

Earlier today, Liu described anaerobic penile dysbiosis: the polymicrobial colonisation of the subpreputial space with anaerobic flora, and its role in HIV acquisition. In her afternoon session, she built on this to describe one of the classic vaginal dysbioses: bacterial vaginosis (BV). BV is characterised by the overgrowth of anaerobic microflora, and reduction of Lactobacilli, and is therefore a vaginal anaerobic dysbiosis. BV is a common condition, and its management is characterised by persistence, recurrence. It is also associated with an increased risk of HIV acquisition, as well as a range of adverse pregnancy outcomes and pelvic inflammatory disease.

What is the relationship between these penile and vaginal anaerobic dysbioses? Are these phenomena sexually transmissible? The anaerobic organisms implicated in both processes certainly have considerable overlap, and evidence from several quarters supports the sexual transmission of BV.

 Liu and her colleagues enrolled 165 uncircumcised HIV-negative Ugandan men and their female partners into the Rakai Health Sciences Cohort. Self-obtained vaginal swabs from female partners were assessed for BV using the Nugent score, while swabs from the coronal sulcus were collected from men for assessment of their microbiome using 16S rRNA amplification.

Penile microbiomes were found to fit into four distinct patterns, termed Community State Types, which ranged from microbiomes with low diversity and few anaerobes (CST 1-3) to communities with very high diversity and a rich population anaerobic flora (CST 4-7): so called anaerobic dysbiosis.  

 Bacterial vaginosis was found more frequently among female partners of men with anaerobic dysbiosis than in men with lower levels of diversity and less anaerobic flora. This supports the hypothesis that anaerobic penile and vaginal dysbiosis are sexually transmissible and results from sharing of anaerobes within heterosexual settings.

 

 Longitudinal studies are needed to prospectively observe transmission events between couples, as well as account for potential confounders such as hormonal factors, hygiene practices and so on. Higher resolution molecular identification tools to better describe phylogenetic relationships between organisms shared by the partners are needed to confirm transmissibility.  

 

On Friday night the ASHM Conference & Events team were announced as winners of the MEA NSW State and National Award… https://t.co/raxog3ZPcG

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Webinar: ASHM’s Regional Advisory Group on BBVs, Sexual Health and COVID-19 presents: Health and human rights for s… https://t.co/LXZvmoL4hm

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