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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The weather has been very kind to us and has been very un-Glasgow like since the start of the congress. For the second consecutive day, a piper welcomed us to the SECC.

It's truly humbling to be in the presence of all these wonderful researchers and inspiring to see all the advances being made in the management of HIV. The focus of many of today's presentations was on HIV and ageing, associated co-morbidities, co-infections, malignancies and mental health. The need for improved screening programs was a recurring theme.

We were again reminded of the 2020 goals which aim for 90% of people with HIV being diagnosed, 90% diagnosed on treatment and 90% on treatment with an undetectable viral load. 

Highlights of the day for me included an interesting presentation on 'ARV Optimisation to meet patient needs' by Mark Nelson from the Chelsea and Westminster Hospital. He referenced a questionnaire/survey conducted by Redlin in 2014 comparing what health care providers and patients considered important when it came to HIV care and ARV therapy. Interestingly, efficacy of treatment was ranked highest and cost ranked lowest by both arms. 

The day was concluded by Fiona Mulcahy of St James Hospital who presented a complex case study of a young immigrant woman with a new HIV diagnosis who was planning pregnancy with her new partner of unknown HIV status. Disclosure was certainly an issue and the consensus was that he should be tested as soon as possible and that she should commence ART. The various options for reducing transmission of HIV to the male partner were discussed, including PrEP. There was some debate and conflicting opinion on how the couple should proceed, though the presenter suggested she would recommend natural conception as long as her viral load was undetectable. 

The congress sadly concludes tomorrow. There are some  exciting presentations to look forward to, including, but not limited to PrEP, the future of ARV's, drug interactions and new drugs. 

 

Day 3.

 

This morning’s session was largely about psychosocial issues in people living with HIV.

 

Moisés Agosto-Rosario (an educator and advocate for people living with HIV) spoke about communication and ways in which we can improve this. He emphasised that it must be patient-focused, and must consider the sensitivities of those “key groups” at risk of HIV (sex workers; MSM; PWID; trans people; CALD people). He finished by stating that by 2020, 70% of people living with HIV will be >50yo (I imagine that this was a US statistic, but he didn’t specify), so we must be prepared for the increase in comorbidities that’ll come along with an ageing population living with HIV.

 

David Stuart (from Dean Street Clinic, London) spoke about the change in culture of the MSM community, with specific reference to:

-       The social scene (hookups often through apps as opposed to in person)

-       The drugs used (crystal/GBL/mephedrone in London)

-       Risk-taking behaviour

Of the HIV-infected patient group they see, several have died in the past 12 months – but all were from drug-related issues (not from HIV/AIDS), highlighting the importance and risk of drug use in this population. He also emphasised the importance of doing “well-being” checks at each visit, including social and emotional well-being.

 

Changes in morbidity/mortality/HIV care – a cohort study over 10 years in France.

Charles Cazanave spoke about research they’re doing in Aquitaine, France, with the ANRS CO3 cohort, to assess how the needs and morbidity of people living with HIV change over time. They had a cohort of n=2138 that they recruited in 2004 and followed until 2014, following their HIV-related characteristics, as well as other patient factors and co-morbidities.

-       71% male (40% MSM)

-       52% were over 50 in 2004 (and obviously 62% in 2014)

-       91% had HIV VL<50 in 2014 (compared with 51% in 2004)

-       72% had CD4>500 in 2014 (c/w 44% in 2004)

-       ART regimens changed little between 2004 and 2014 (except integrase inhibitors being used in 6.5% in 2014).

-       Dyslipidaemia rates increased by 40% and hypertension by 37% over the 10 years

-       Cardiovascular (increased by 6.1%) and CNS adverse events increased over time; rate of people with EGFR<60mL/min increased by 5.1%; those with Framingham score indicating high risk increased.

Unfortunately there was no control group with which to compare these increases. However they concluded that monitoring for and management of co-morbidities is imperative in an ageing population with HIV.

 

Effect of lipodystrophy on morbidity/mortality.

Esteban Martinez presented research on the connection between lipodystrophy on risk of morbidity and mortality – their hypothesis was that lipodystrophy may increase the risk of comorbidities/mortality in people living with HIV.

They studied a population (n=494) that began CART between 1996 and 1999 – this CART initially involved 2 x NRTIs and at least 1 PI. 76% were men; 28% were MSM; 39% IVDU. Follow-up was until Dec 2015 or death (14%) or loss to follow-up (21%).

-       24% had lipoatrophy

-       4% had lipohypertrophy

-       18% had lipodystrophy (both lipoatrophy and lipohypertrophy)

Analysis of death rates, morbidity and lab testing by the end of Dec 2015 revealed:

-       Fewer AIDS events and fewer deaths in those with LA/LD, however no association with lipohypertrophy (however note the small number of people with lipohypertrophy).

-       Less hepatic decompensation in those with LA/LD.

-       Hypertension/diabetes rates increased in those with LD/LA/LH.

Conclusions were, unsurprisingly, that lipoatrophy was a proxy for effective CART and viral suppression, so morbidity/mortality overall less in this group.

 

Dolutegravir and cessation due to neuropsychiatric effects.

Michael Sabranski presented an analysis of all those beginning integrase inhibitors in Germany between Jan 2007-April 2016. All discontinuation reasons, start and stop dates were analysed.

-       In those that took dolutegravir, other covariables were analysed.

N=1704

The study found that:

-       The discontinuation rate of dolutegravir due to neuropsychiatric adverse effects was almost 6% within 12 months – this rate was higher than that reported in RCTs (and higher than for raltegravir/elvitegravir)

-       Women, older patients and patients who simultaneously initiated abacavir had a 2-3 fold higher risk of DTG discontinuation due to neuropsychiatric adverse events.

-       Such adverse events were reversible and not severe.

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It was acknowledged that a higher rate of people ceased DTG in 2016 (after research had already come out linking DTG with neuropsych side-effets. However even when those patients were removed, the relationships listed above were still significant.

Today began with an interesting talk by Prof. Julio Montaner. He spoke about HIV treatment as prevention (TasP) – I found it interesting that based on a couple of models (from Hlabisa, Africa and BC, Canada), for every 1% increased coverage (with ARV and undetectable VL), one can estimate a 1% decrease in HIV incidence.


Prof Montaner also presented research on the HIV strains found in British Columbia. Phylogenetic studies of the strains found show that, even with high rates of diagnosis, treatment and viral suppression (Vancouver on-track to reaching 90/90/90 goals by 2020), significant clusters of new infections still continue to occur, and that investigation, prevention and treatment strategies must focus on these clusters. Contact and partner tracing were strongly emphasised.

 

 

Jens Lundgren spoke next regarding the START (early ART) study update.

-       Hazard ratio of 0.43 of serious AIDS/non-AIDS events in early treatment arm (compared with delayed treatment) – so unblinded early.

-       Significantly decreased rates of OI in early treatment arm.

-       Cancer occurrence had a 64% risk reduction in early treatment arm.

-       No evidence of a change in hazard ratio for cardiovascular disease; no evidence of a change in FEV1 between arms; no evidene of different in neuropsych testing results.

-       Bone mineral density testing showed total spine BMD decreased in immediate vs delayed ART – clinical implications unclear.

 

Chloe Orkin spoke about a couple of studies involving TAF – study 1089 involved switching from TDF to TAF in those virologically suppressed. n=663; all initially on TDF/FTC + 3rd agent. Half had TDF switched to TAF.

-       No difference in rate of discontinuation or adverse events between arms.

-       No difference in efficacy at 96 weeks – TAF/FTC noninferior.

-       Average EGFR and BMD improved in TAF arm.

-       Slight increase in LDL/TC in TAF arm, but no change in total cholesterol:HDL ratio.

 

Finally Patrick Sullivan spoke about the importance of convenience in improving HIV care. He discussed strategies including:

-       Integration into routine clinical encounters

-       Self-service options

-       Home delivery of investigation/treatment/PrEP

-       Reminder systems for routine screening.

His team has developed a mobile app called Healthmindr (still under trial and only US-based I think) that helps with behaviour screening, PrEP assessment and advice and reminders about STI screens.

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They’re also trialling STI testing and PrEP at home – involves initiation and follow-up to three months in the clinic, then visits and monitoring after that can be done at home (a kit is mailed and self-collected swabs/FCU/blood tests, as well as survey). Acceptability has been high and sample quality adequate.

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Glasgow HIV 2016 has just opened.

It was interesting to hear new-comers to this meeting reflect on the three excellent presentations in the opening: Clarity, different perspectives, and reflections mixed with predictions. The sessions will be up on the Conference website shortly.

Tony Fauci, giving the Joep Lange and Jacqueline van Tongeren Memorial Lecture. Ending the HIV/AIDS pandemic: follow the science, reflected on the changes that have come about since he entered the field in 1981, following the publication of seminal articles in the MMRW. Fauci indicated that this is when he decided to change his career trajectory and concentrate on the, as then un-named, phenomenon which would become HIV.

Fauci sprinted through 30 years of HIV to focus on the more recent research which has redefined ending HIV. Namely the recognition that treatment reduces virus which in turn reduces transmission and that knowing ones status allows for interventions. But he did not stop there. He went on to cast and eye to the horizon and identified two areas where science has significant contributions to make.

HIV persistence, or stopping persistence, is a holy grail. This comes in two forms, eradicating HIV where HIV is made dormant while treatment is administered, yet re-emerges when treatment is stopped or controlling rebound, where interference at binding or replication sites reduces proliferation. This individualised therapy has shown to be useful in this strategy in cancer treatment and it has potential in HIV.

HIV vaccines, whether therapeutic or preventative are of course what everyone is hoping for. Fauci presented some realistic steps which are being made to transition vaccines from 32% effective to more like 50% effective, a point which he suggested could make significant inroads in reducing transmission, particularly in endemic settings and in combination with other strategies. He also discussed a number of new vaccine initiatives.

He ended with neat summary of why vaccinologists have not yet been rewarded. This I thought was a poignant rationale for continuing with vaccine development in the absence of any hitherto prizes. Most vaccines mimic the actual process of disease and immune response. That is not the case in HIV, so the vaccinologist needs not to copy the virus, but be much smarter than it.

 

Andrew Hill

Spoke about the potential to improve treatment access through the greater use of generic drugs. I can’t help thinking every time I hear Andrew talk that he is simplifying something in the greater economics and practicalities of capitalism or financial markets. But his arguments are very compelling.

Interestingly Andrew inserted discussion about Australia’s funding for hepatitis C treatment. Having just come from the USA where I was asked about details of the same, it seems to me that there are very different mechanisms in place in different countries which can result in very different approaches to price setting.

Two years ago at this meeting Andrew suggested it might be in the interests of the NHS budget to make a two pill (rather than single pill) regimen available to the UK public through the NHS. This brought criticism from at least one senior Australian clinician and commentator who thought that it would be unacceptable to expect patients to take a less convenient regimen.

Linda-Gail Bekker

As always presented clearly and passionately about the current experience of HIV in Africa and was able to compare and contrast this to other global settings. She is able to mix population and locational differences and introduce a third dimension of how these interact.

Adolescents were for a long time not a priority in HIV prevention. Key affected populations, are largely characterised as being “the-non-majority population”. While recognising this, she introduced an emerged KAP in Africa and that is adolescent women.

Linda-Gail was able to focus on trends which demonstrated changes for the good. It was very interesting to see a map where Australia was pink (on a blue to red scale) for increasing or sustained new infections. While our numbers might not be big they seem to be somewhat intransigent. Many African states have seen dramatic improvements. While more developed settings seem to be finding it difficult to make changes to address persistent, comparatively low-level, new infections. Something which Fauci also recognised in the USA. It would be interesting to see Andrew Hill’s economic assessment of the cost of these different interventions.

A great opening session which augers well for the coming days.

Levinia

 

 

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Australasian Viral Hepatitis Conference: Cross Track Session - Viral Hepatitides

Scott Bowden, Senior Medical Scientist, Victorian Infectious Diseases Reference Laboratory (VIDRL) spoke on hepatitis A in Australia. Hepatitis A is the most common hepatitis worldwide. Scott provided a good summary of the hepatitis A virus structure and worldwide prevalence. He then went on to relate the three largest outbreaks of hepatitis A in Australia, including the most recent involving frozen mixed berries imported from China.

 

Kathy Jackson, Senior Scientist, also of VIDRL, spoke on the hepatitis delta virus (HDV) in Australia. HDV is the least common form of viral hepatitis but leads to the most severe liver disease. HDV is a "satellite virus" which can only exist in the presence of the hepatitis B virus. There are currently no national testing or treatment guidelines for HDV. VIDRL recommends testing first anti-HDV, and if positive followed by a HDV PCR, and then viral load (if required for treatment monitoring.

 

Dr David Siebert, Infectious Diseases physician and microbiologist at the Princess Alexandra Hospital in Brisbane gave an update on the hepatitis E virus in Australia. Hepatitis E is an emerging infectious disease in industrialised countries and is not simply a travel associated infection. Hepatitis E virus should be considered when a patient under immune suppression presents with acute hepatitis. Currently there is no screening of blood products for hepatitis E, making the transmission of hepatitis E through transfusion inevitable in Australia.

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