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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Satellite Session:

Fantastic expert  panel presentation informally discussing reality of target and inviting audience participation

Consensus a Challenging target

Possible to eliminate as Public Health threat if role out of new treatment continues

Treat as prevention to decrease new infections

Do need vaccine as resistence possible

Possibly Realistic target have the tools, systems, funding

Need to ENGAGE people

Large population of HCV , it is not their priority

greater 40,000 treated  by end year but  many still not aware treatment availability, also ageing population

Need GP's to take up treatment

need to test, need good history taking ,use database

Remember STIGMA prevents accessing GP

need to increase training for GP's in Hep C and treatment

Open treatment landscape

Move out of Hospital specialist, GP could  use if not got skill set

Target will need massive investment for Aboriginal Medical Services

15-24 ages :Indigenous 8x higher Hep C rates

Increasing IVDU under acknowledged

And Prison

Will need sysrems to monitor who is on treatment

think treatment as prevention, frame positively, can cure

Solid plan to include Primary care, main contact point for Indigenous population

HIV coinfected treat early,  care re reinfection but Caution STIGMA

Remember DDI, be aware

HCV and HIV VL not an issue

BUT noted easy for the experts to say  need to role out updated info and guidelines for GPs

Reinfection main risk Prisons

Discussion around barriers to OCT (opiod substitute therapy/methadone)

Difficult to access in prisons....THE DIFFICULT area despite funding

NEED SAFE INJECTING PRACTICES and regulated needle exchange

30% Indigenous in prisons including youth

SA making inroads re strategy

Reminder Indigenous mobility 

Suggests Research grant re what it would take to get to target in Indigenous population

Cairns area low IVDU BUT caution change

Prison Mareeba attitude to treat prompt and often

Remember to look GLOBAL

Reminder of costs and increasing problem crystal meth

Problem HePC treatment still mainly metropolitan area

Need strong GP networks

Resistence in initial HCV regimes not a problem if Fail may need 2nd line

Need traditional Public Health approach

Indigenous population need treatment as prevention and to hear benefit of cure

Discusion re HIV group take on HCV as experienced

Need to be realistic, limited specialists,liver clinics problematic

Use of NPs

Need to be able to write prescriptions....in the pipeline

Overall consensus came at role out was backwards

Ivory Tower Not as Public Health problem

Approach should have been: 

ASSUME population dont know

Hep C much more prevalent

GET tested

Treatment can cure

Access to clean needles

Implement systemic changes in Primary care

Who are pos

Who is on treatment,adherence

Chronic care plans......

Overall great opportunity to see where the new treatment role out is at with a target date set for HCV elimination...

and opinions at what needs to be done 

Highlighted the continuing shame to ignore Indigenous population requirements, 

We once promoted safe injecting,needle exchange....

The title Australia leads the world is not deserved until it is truly inclusive to its Indigenous population needs

 

 

 

 Cindy Liu from the Milken Institute School of Public Health, George Washington University presented her findings on the relationship between the penile microbiome and HIV susceptibility. Liu hypothesized that the penile microbiome drives pro-inflammatory responses and in turn increases HIV acquisition.

 The space underneath the foreskin is a unique environment with a characteristic microbiome. Analysing subpreputial swabs from men in Uganda, Liu and her colleagues used molecular techniques to investigate bacterial populations prior to and after male circumcision. 16S rRNA sequencing was employed to characterise bacteria to genus level, and a pan-bacterial DNA RT-PCR was used to quantify total bacterial load. Together, these were used to estimate the absolute abundance of specific bacterial taxa in the subpreputial space.

Prior to circumcision, the subpreputial space was characterised by a diverse bacterial community that varied between individuals and over timel. A wide variety of anaerobes, including Prevotella, Finegoldia, Peptoniphilius, and Aerococcus, were isolated in high numbers. Post-circumcision, the populations of these anaerobes reduced, and resembled flora from other skin. Anaerobes decreased, populations became less variable, and Lactobacilli increased.

 Expanding on this, the investigators examined the immunological responses to these changes in the microbiome. Langerhan cells, the antigen-presenting cells par excellence of mucosal surfaces, are thought to be integral to HIV acquisition. In the inactivated resting state, Langerhan cells ingest HIV virions, and lyse them prior to presenting the lysed products to lymphocytes at the lymph node. In activated Langerhan cells however, degradation of HIV virions is bypassed, resulting in presentation of intact virus to nodal lymphocytes and the commencement of viral replication. Anaerobic flora were postulated to be triggers for Langerhan cell activation.

  Liu found that IL-8, one of the key cytokines implicated in immune activation, was significantly higher among men colonised by Prevotella, and other key anaerobic organisms.  IL-8 is known to attract neutrophils along a chemotactic gradient, and induce them to release MIP 3a alpha and MCP-1, which in turn lead to recruitment and activation of CD4+ T lymphocytes, drawing them closer to the epithelial surface.

 This work supports the hypothesis that an anaerobic subpreputial microbiome induces pro-inflammatory local immune responses, and that these changes are negated by male circumcision.

 Further work on the correlation between the penile microbiome and HIV acquisition is keenly awaited. Liu’s current collaboration with the Kirby Institute will examine the role of the ‘dorsal slit’ modified circumcision commonly practiced in parts of PNG, and will hopefully give insight into this cultural practice’s potential role in HIV prevention.

 

Gonorrhoea in MSM: Is kissing a major means of transmission?

Main Points:

  • Significantly higher rates of gonorrhoea in MSM compared to heterosexual men => Why?
  • Much higher incidence of of pharyngeal gonorrhoea in MSM compared to rectal infections & urethral (urethral = lowest)
  • Prevalence of pharyngeal gonorrhoea in MSM is ~ 11% => ??why so high compared to other sites, especially when anal sex &/or oral-penile, oral-anal sex is reported to be LOW
  • Working hypothesis: pharyngeal gonorrhoea is most likely transmitted through kissing, ?related to high rates of MSM kissing multiple partners in e.g. clubs & pubs

Personal reflection on personal practice => I remember a patient who was married (to a woman) who frequently engaged in MSM sex. This patient was Dx'd with pharyngeal gonorrhoea & stringently denied any sex with his wife for a very long time but had kissed her. His wife was admitted to hospital with Reactive Arthritis related to gonorrhoea infection. Based on patient report: the only possible means of gonorrhoea transmission to his wife could be through kissing

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Pharyngeal infection with Neisseria gonorrhoea represents a large, asymptomatic reservoir of infection, and is thought to be an important driver of transmission among men who have sex with men (MSM). Which sexual activities drive the transmission of gonorrhoea between the pharynx and other sites? Could it be oral sex? Rimming? Chemsex?

Kit Fairley, Professor of Public Health at University of Melbourne and Director of Melbourne Sexual Health, wonders if it might be all even more surprising - kissing. But not just any kissing - 'proper kissing with a tongue and all the rest of it.'

In  a thought-provoking presentation, Fairley points out that gonorrhoea rates are highest among young MSM, and fall with age. While this might suggest a degree of acquired immunity to gonorrhoea, it might simply reflect changes in kissing throughout the age spectrum. Rates of oral sex, the traditionally accepted route of transmission to the pharynx, do not fall with age. Furthermore, penile-oral sex relies on urethral gonorrhoea as the vehicle for transmission between pharynges of different partners. Urethral gonorrhoea, however, is almost always symptomatic, and urban MSM are quick to access health services early in the course of gonococcal urethritis. 'The penis' says Fairley 'is an innocent bystander in this whole affair.'

How plausible is this? Neisseria meningitidis, the organism from which N. gonnorhoeae evolved aeons ago, is readily transmitted through saliva, and kissing is a well-recognised and important route of transmission for the meningococcus. N. gonorrhoeae, or at least it's DNA, can be readily detected in saliva of those with pharyngeal infection. 

If this hypothesis is correct, something as simple as antibacterial mouthwash might crack the transmission dynamics of gonorrhoea and spare the need for cephalosporins. And besides, who wouldn't prefer to kiss a man with fresh, minty breath?

Gollow Lecture by Rebecca Guy:

  • Focus on the ever-increasing utility of the various (existing, new & emerging) IT platforms & applications for:
  1. improving client & patient care experience
  2. increased efficiencies / time savings for clinical staff and thus also for the service as a whole
  3. the potential and actual role(s) for technology to be utilised in both primary & secondary prevention

Examples of efficacious technology utilisation:

  • Sydney Sexual Health:
  1. electronic patient self-registration + appointment self-arrival system reduces the amount of time spent in reception by (a significant) 4 minutes
  2. Benefits of CASI (computer assisted self interviewing): "most people don't want to discuss their sex lives in detail with doctors and nurses" => much easier to respond honestly to questions on a screen than go through the 'gruelling agony' of a face to face interview with a clinician
  • Computer prompts for GP's shown in one study to increase opportunistic testing of e.g. chlamydia by a significant 30%
  • Significant improvement in partner notification via websites such as 'Drama Down Under' & 'Let Them Know'
  • Significant increase in re-testing rates utilising an SMS reminder system (NB: ~20% of people have a reinfection within 12 months of a +ve result) => in 2009 SSHC instituted an SMS reminder service. Result: 64% return rate for re-testing; a significant increase in re-testing rates vs a verbal recommendation after Rx. of the first infection
  • * Very interesting 'side discussion' re: the use of online dating & hook-up apps => not only the domain of the young; rather, people of ALL ages are using these platforms. Also of note => people who use these online / dating apps are more likely to have had an STI in the past & more likely to have a higher number of casual partners
  • ?? The Future:
  1. Online Clinics?
  2. Home STI testing?
  • Finally: Rebecca promoted clinicians to access the freely available Kirby Institute Data sets: http://www.data.kirby.unsw.edu.au/

ASHM is pleased to launch our recently updated General Practitioners and HIV resource. You can download the resourc… https://t.co/UVP72mrTeP

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