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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Plenary Lecture: BIG (data/mistakes/Brother)

After a morning spent walking off jet lag and discovering Milan, the conference opened after lunch.  After a fascinating round table on PrEP which Rebecca and Emma have blogged about it was time for the first plenary lectures.

Dr Robert Alexander specialises in medical IT at IBM in Italy and gave a fascinating and slightly scary overview of the magnitude and importance of data currently and into the future. He pointed out that as humans we are pattern recognition machines and use this in diagnostics. He showed the mind boggling facts about how much data is transferred in 1 internet minute in 2017: 

He pointed out that each of us will produce about 1tB of health related data in our lifetime. Also we will have more and more sensors either worn or implanted generating real-time health data, (think smart watches and pacemakers!)

Data is going digital with pathology and genomics/proteomics following radiology and demographics.

 

Health data only comprises about 10% of available human data and this comprises 10% of data that would impact on an individual’s health outcomes, so we are only scratching the surface. How do we access the "dark data" below? Well, Robert described the Data Scientist as the "sexiest job of the 21st Century!

A very inspiring presentation given by A/Professor Phillip Mills that cuts to the core of the problem of the sub-optimal success often seen in many indigenous health programs, being namely that of the lack of genuine community engagement in the development and implementation of these programs.

Mills described this as a sort of unconscious neglect that is a manifestation of the dominance of mainstream culture in policy and program development, and ultimately a form of institutional racism.

For any hope for this to be addressed, he gently described the urgent need for a reckoning with Australia’s colonial past and a shift in collective consciousness of the general population.

A very important message for those working with indigenous populations.

Access speaker presentations from this session via the AVHEC17 website

 

Phillip is a Kulkulgal Tribal Elder of Zenadth Kes and Associate Professor with the Australia Institute of Tropical Health and Medicine (JCU) and has authored and co-authored award winning research papers, chaired scientific and inter-departmental committees and sat on ministerial policy committees on Indigenous Health. Phillip led the reform in indigenising the Public Health System as Executive Manager of mainstream Hospitals and Primary Health Care whose core mainstream business was Aboriginal and Torres Strait Islander Health with the establishment of specifically tailored evidence based scientific Indigenous Health Models. The success of his work in community developed scientific health interventions, culturally acceptable health care systems and protocols, and innovative evidence based bi-cultural health practices and structures earned him an Order of Australian Award Medal. His expertise has flowed on into the Community Control Sector where the application of his work has assisted enhancing the development of more comprehensive primary health care.

 

 

Tagged in: AVHEC 2017

The day started with a presentation from Prof. Jeanne Marrozzo, Professor of Medicine and Director of the Division of Infectious Diseases, University of Alabama, Birmingham.

Key points - 

* colonisation of a newborns gut is dependant on the type of birth

       ^ Caesarian births result in the newborns gut being colonised with skin flora eg staph aureus

       ^  Vaginal birth results in the newborns gut being colonised with healthy lactobacillus     

       ^ With the high rates of Caesarian births in developed countries, the practice of introducing the mothers           vaginal secretions into the mouth and nose of the caesarian born neonate may need to be seriously considered.

* Women with Bacterial Vaginosis (BV) have a 60% higher risk  contracting HIV through vaginal sex

* HIV neg men whose HIV+ female partner has BV are more likely to contract HIV

* one outcome of the VOICE study revealed that women using tenofovir vaginal gel who had a lactobacillus dominant vaginal biome had a lower risk of contracting HIV, compared to those with a lactobacillus non-dominant vaginal biome.

* maintenance of a healthy vaginal environment might reduce the risk of contracting STI/HIV, further research is required to establish how this is achieved, particularly to establish the pathogen that causes BV

The afternoon continued along the vaginal microbiome theme with several presentations:-

Dr Ricardo Diaz, University of San Paulo Brazil

* Gardnerella Vaginalis reduces the levels of TDF-DF in vaginal fluid

Olimade Jarrett MD

* The presence of P. amnii and S. sanguinegens in vaginal miceobiome was associated with a 3.5 to 4-fold increase in rates of Trichomonas vaginalis infection

Charlotte Van Der Meer

* The Dutch study on Effect of intra-vaginal douching on the vaginal mucosa suggests that use of intra-vaginal douching has no effect on vaginal microbiome, but may increase the risk of developing a candida infection. 

Such an exciting area of research, where so much more knowledge is needed to reduce risks of acquiring HIV, STIs, and those pesky vaginal conditions. 

Comment:

The significant rise in symptomatic and asymptomatic STIs in recent years is having a huge impact on clinical practice. Many practices struggle to manage additional presentations to test and treat those with STI symptoms and to organise treatment and followup of those with positive test results. I have also noted an increase in requests from MSM on PrEP for private Doxycycline scripts for syphilis prophylaxis.

A number of trials are underway to address the topic and it's important to acknowledge that, at present the evidence is minimal. The list of potential adverse consequences is however, a lengthy one.

The rate of HIV resistance in those who acquire HIV while taking PrEP is small..... but we're only focussing on one pathogen. There are numerous bacteria in different organ environments upon which Doxycycline prophylaxis may have an impact. While there are concerns about emerging bacterial resistance in STIs such as Gonorrhoea and Mycoplasma Genitaleum, it is essential that we explore resistance in other organisms at other sites to fully characterise the problem.

Further, intermittent antibiotic use may alter the clinical course of infection (eg Mycoplasma Genitaleum) and partially treat STIs such as syphilis, confusing interpretation of results and management issues further.

The vaginal and penile microbiome have been discussed at several sessions at CROI, and I also wonder what impact antibiotic use may have on such microbiota, and whether this could increase HIV transmission (eg BV being linked to increased transmission)?

This is an important topic and worth understanding some of the complexities so that we can educate individuals seeking prescriptions now, in the absence of evidence.

 


I've summarised Jean Michel Molina's presentation below:

55 ANTIBIOTIC PROPHYLAXIS FOR STIs: PROMISES OR PERILS

Jean-Michel Molina,

 Globally, more than 1 million STIs are acquired daily, and annually approximately 146 million of new infections with chlamydia, 78 million of gonorrhoea and 6 million of syphilis are diagnosed. In the US, 2015 was the second year in a row with an increase in STIs, with syphilis increasing at an alarming rate among MSM. Implementation of PrEP for HIV prevention has also highlighted the increasing incidence and prevalence of STIs in PrEP users.

 Current efforts to contain the spread of STIs are obviously not sufficient and should include:

              - promotion of condom use.

              - counselling and behavioural interventions.

- vaccinations for viral STIs (Hep A and B, HPV).

- scaling up more effective STI service.

- increased testing for STIs in high risk individuals for early diagnosis of symptomatic and asymptomatic infection.

- better notification and treatment of sex partners.

- new biomedical interventions: Antibiotic prophylaxis?

 

The success of PrEP for HIV has raised interest in biomedical interventions for STIs. Pending the development of vaccines against bacterial STIs, the potential role of antibiotic prophylaxis should be re-assessed.

Studies conducted by the military have shown the short-term efficacy and the limitations of post-exposure prophylaxis. More recently, periodic presumptive treatment in female sex workers with azithromycin alone or in combination have shown reduction in incidence of gonorrhoea and chlamydia but not of syphilis or HIV. Mass treatment with azithromycin for trachoma and Yaws elimination has also shown some impact on STIs prevalence.

Studies using doxycycline prophylaxis for syphilis in high risk MSM are ongoing. Should antibiotic prophylaxis be successful at reducing STIs incidence, the short-term benefits should be balanced against the potential for adverse consequences:

 

              Short term reduction in STI prevalence with rebound to pre-intervention rates:

              - Selection of antibiotic resistance.

              - Change in sexual behaviour/risk compensation.

              Changes in STI presentations:

              - Prolongation of the incubation period (delayed seroconversion).

              - More frequent asymptomatic carrier state with extragenital locations.

              - Emergence of new STIs resistant to chemoprophylaxis (eg Mycoplamsa Genitaleum).

              Selection of antibiotic resistance:

              - Selection and clonal dissemination of drug resistant STIs.

              - Reduction of already limited treatment options.

              - Impact on human microbiome: Drug resistance in other pathogens (eg Staph Aureus)

              Tolerability

              Cost

 

New strategies need to be developed to contain the spread of STIs. Antibiotic prophylaxis for bacterial STIs in high risk populations should be carefully evaluated.

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Hi from Seattle. 

Very interesting plenary this morning at 8.30 presented by Jintanat Ananworanich. She spoke about the potential and possible processes for cure. It was a very good overview. She specifically discussed what can be learned from the way the immune systems of infants and children respond to HIV and how that can inform us in regard to potential for cure. Well worth watching the webcast on the CROI site when it becomes available in a few hours.

 more to come 

 

Tagged in: CROI 2017

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