HPV

• SPANC: http://kirby.unsw.edu.au/projects/study-prevention-anal-cancer-spanc

1. Prospective 3 year study on anal HPV in older gay/MSM i.e. 35 years & older; important because this will be a mostly unvaccinated cohort
2. HPV 16: ~ 50% of all HPV related cancers plus it is the type least likely to be cleared
3. HSIL (high grade intra-epithelial lesion): found in 30-50% of HIV +ve men
4. Cochrane review: there is no current evidence that treatment of high grade lesions prevents progression to cancer
5. Research being done into the potential for anal cancer biomarkers to predict disease persistence

Syphilis

• Australian surveillance data 2006 - 2015: 14,200 notifications for syphilis
  
• Indigenous Australians are 6 times more likely to be infected with syphilis
  
• Significant increase in syphilis in MSM during the 10 years to 2015
• Rates of syphilis in MSM in Victoria => approx. the same rates in both HIV +ve & HIV -ve men (differs from epidemiology data in other jurisdictions where the rates of syphilis in HIV +ve men tend to be far higher than in HIV -ve men)

Gonorrhoea

• Studies into gonorrhoea site-specific infections in MSM couples => the number of gonorrhoea infections in certain sites did not correlate with the expected # of infections (in certain sites) when considering reported sexual behaviours e.g. far more throat infections than expected => leading to the hypothesis that kissing may be a significant factor in gonorrhoea transmission
  
• Condom use: even when condom use is reported to be high (for anal intercourse) there was no significant difference in the rates of gonorrhoea transmissions overall

IDU

• significantly higher numbers of all STI's in IDU vs non-IDU
  
• far more HIV +ve MSM inject drugs vs HIV -ve MSM

Testing for MSM

• Community based testing services are far more likely to attract gay/MSM plus have a significantly higher STI yield when compared to non-community based services. Conclusion: very important to maintain community based testing services
  

Very interesting presentation of transmission of pharyngeal Gonnorhoea.

Take home points:

• Not likely to be transmitted penis -> throat / throat -> penis as commonly thought.
• Likley transmission mechanism is via saliva. Deep kissing and use of saliva as lube
• Pharyngeal Gonorrhoea may be more prevalent in younger age groups due to higher levels of kissing
• Worth rendering to ensure swab of throat even if clients report no oral sex 
• ?could anallingus be a mode of rectal transmission?
• Daily antibacterial gargle may greatly reduce load of pharyngeal Gonorrhoea

Bacterial vaginosis (BV) is a polymicrobial phenomenon that represents dybiosis or imbalance in the vaginal microflora. Gerald Murray today presented the findings of a cohort study that examined the relationship between the vaginal microbiome and BV.

298 women without BV underwent periodic assessment of their vaginal microbiota by 16s rRNA sequencing. Over two years of follow-up 51 women developed BV, giving an incidence of 9.75/100 woman-years. 

Certain taxa were associated with subsequent development of BV - a 1% increase in Gardnerella vagainalis conferred a 2% increase in BV. The poorly characterised, non-cultivable BBAV TM7 was associated with a 5-fold increase in BV, but Atopobium vaginae was not. 

Diversity of the vaginal flora was correlated with susceptibility to BV. Women with more diverse microbiome experienced greater fluctuations in flora between assessments, and these unstable microbiomes were more likely to develop BV. Interestingly, the acquisition of microbial changes associated with an increased BV susceptibility often preceded the development of clinically apparent BV by weeks or even months. 

Behavioural factors were also associated with the development of BV: a higher rate pf partner change and the acquisition of a new partner were associated with incident BV. This is consistent with the emerging view of BV as a sexually transmissible phenomenon. 

Then authors  hypothesise that BV is a sexually acquired instability in the vaginal microbiome that ultimately leads to a lack of resilience in a complex community. 

It was the final day of this  truly wonderful global congress. 

Chloe Orkin of the Department of Infection and Immunity at the London Hospital co-chaired the opening session of the day and discussed some great advances in HIV research this year including:

. Phase 3 TDF v TAF trials

. Injectable PrEP

. ?generic 3TC/TDF

. New delivery methods

. New molecules

Sheena McCormack of the MRC clinical trials unit at University College London provided us with PrEP updates and effectiveness, highlighting:

. the overwhelming evidence of its efficacy

. Population effectiveness not compromised by resistance

Based on the evidence, she concluded that moving into the future, there will be more drug choices for PrEP, different regimen choices (episode driven) and a multitude of delivery methods (vaginal rings/injectables).

One of the day's most thought provoking presentations was delivered by Keith Rawlings from Gilead Sciences medical affairs. He reported that despite a steady increase in PrEP use since 2012, data showed there was a huge discrepancy in those who accessed it. He stayed that it was heavily weighted towards middle class caucasian MSM.

This was despite an increased lifetime risk of HIV acquisition of:

. 1:20 for African American males

. 1:48 for African American women

. 1:48 Hispanic males

 And when broken down further:

. 1:2 African American MSM

. 1:4 Hispanic MSM

as compared to 1:11 in Caucasian MSM

FTC/TDF for PrEP has been disproportionately low in the higher risk populations in the USA.

It was recommended that to effectively decrease new HIV infections, messaging and services need to be more focused on those populations with the greatest disease burden. 

It's been an incredible 4 days here in Glasgow which has sadly come to an end. I look forward with great anticipation to the next Glasgow HIV Drug Therapy Congress 2018 and anticipate further advances will continue globally in HIV management thanks to the many innovative and brilliant researchers working in the field.

Speaker - Brian Pence from the University of North Carolina 

His talk addressed a very common barrier to HIV care and treatment - mental health concerns, discussing  previous publications in the early years of the epidemic about responding to psychological crisis of HIV/AIDS. It is still a challenge faced by many of us, more than 30 years later. He gave an overview of psychological trauma and the heavy burden of stressful life events of many people living with HIV leading to chronic mental health issues in addition to stressful risk behaviours, immune suppression and side effects of antiretroviral therapy.

He showed data on depression and mortality in modern ART era from the WIHS cohort (in press) as well as in the early ART era from HERS cohort (Ickovics et al.JAMA 2001) where chronic depressive symptoms were reported commonly in patients with CD4 <200. 

Barriers to addressing mental health concerns among people living with HIV;

• Lack of mental health expertise in HIV care settings
• Stigma around mental health services
• Access to specialty metal health services
• Fragmentation of care

The concept of depression care managers where a nurse, social workers or a medical assistant is trained to assess and help clients with depressive symptoms under the supervision of psychiatrists,helping the HIV care providers to deal with mental health concerns of patients was a highlight in his talk.

The ways to move forward - it is necessary to think of,

• How best to integrate evidence-based mental health approaches into HIV care
• How to engage patients in mental health services
• How best to address multiple psychiatric co-morbidities
• How best to integrate mental health treatment with other adherence/retention support strategies