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.

Workforce Development

Brief video created today to help increase knowledge for GP's on DRE exam for MSM.

I hope that it will help increase knowledge and practice within the GP community. I will continue to share response from my GP colleagues as they interact with the video.

Very excited to be able to walk away from this conference with some proactive resources that may help increase knowledge beyond those who attended.

Specail thanks to Dr Ong for this time and expert knowledge.

Learn more here: http://www.anal.org.au/clinician

Most studies from United States.

Traditional patient referral - patient tells partner go to the doctor, you may have an STI.

Assisted patient referral - patient uses some aid e.g. fact sheet, online notification websites.

Patient Delivered Partner Therapy (PDPT) - strong evidence that this was better than traditional patient referral, but no better than other assisted patient referral.

Considered safe - no episodes of anaphylaxis or major events.

Decreased the incidence of chlamydia and gonorrhoea in a US state by about 10%.

Some studies gave the medication, others provided a prescription for it to the pharmacist.

The prescription was taken up as readily as the direct supply of medication in studies.

Fewer than half of pharmacists knew PDPT was legal. Pharmacists may need training.

In Australia it was thought that PDPT could be used to obtain medication to disguise child abuse.

Consultations are underway to use a phone number on a prescription rather than the traditional patient address to facilitate PDPT prescriptions in some states.

How do we get this into primary care and get GPs to adopt it?

One of the things that the HIV/AIDS pandemic did was to bring sexuality and sexual health medicine into the fold.

Sexual behaviour is complex.

Disciplines from the laboratory services to the epidemiologist, psychologist, social worker or nurse.

There is a vast array of environmental factors that contribute to behaviour and risk taking that a multidisciplinary approach is well suited to untangle.

Evaluation of one-stop-shop models of sexual health service provision.

One-stop-shops offer the most efficient way to provide sexual health services.

We are good at collecting data on soft outcomes, like are patients happy with the service, were they treated with respect, was their confidentiality preserved, etc.

We are not good at collecting evidence on hard outcomes like reduction in teenage pregnancies, STI rates, or behaviour change etc.

MSM still prefer the GUM model of provision.

Heterosexual men prefer the one-stop-shop model because they feel that family-planning services are for women only, and they are distrusting of the confidentiality offered by General Practitioners.

 

Integrating services in one-stop-shops, e.g. HIV services introduced stigma and deterred women from attending.

Staff at one-stop-shops was mixed, with some staff feeling excited that they offer a good service, and others feeling there was less opportunity to specialise.

Are some services better off set apart from integrated sexual health services?

Integrating alcohol interventions into sexual health care.

There is a plethora of evidence to suggest that alcohol is probably the main predictor of unprotected sex and numbers of sexual partners.

Brief interventions has not demonstrated any significant reduction in alcohol consumed or sexual risk rates after 6 months suggesting this is not a cost effective approach.

Substance misuse and sex - chemsex.

Prolonged periods of often unprotected sexual activity, with multiple partners and multiple drugs.

A small number of studies show fairly intensive behaviour modification interventions can reduce chemsex behaviour.

PrEP is now another option.

Can we integrate these services into the one-stop-shop model or should we be referring off to more specialised services.

There is a strong rationale for school based sexual health clinics.

Takes services closer to one of our key service user groups.

There is little evidence whether they work or not.

There is some evidence of reduction of teenage pregnancy and chlamydia rates but the fact is it has not been looked at well.

In fact, there is little evidence that sex education reduces pregnancy or STI rates.

Abstinence only interventions were found to be completely ineffective.

Posted by on in Workforce Development

Testing for rectal chlamydia in women: is it worth it?

Heterosexuals are the ones doing most of the anal sex.

2-3 fold increase in the amount of anal sex in females since the mid-90s.

3-5% rectal chlamydia prevalence in heterosexual women and men.

Recommended rectal testing in those who report ever having anal sex or are symptomatic.

Rectal swabs taken in 18.7 % of women presenting.

Swabs are more likely in sex workers, bisexual women, older age group, and those recalled for testing.

Urogenital swab positivity rate is 7.5%.

Rectal swab positivity rate is 8.3%.

70% of infections were rectal and vaginal.

11% were vaginal only.

19% were rectal only - and all had no rectal symptoms, so would have been missed, meaning we would miss 1 in 5 chlamydia infections.

Anal intercourse is rarely asked during history taking.

It can include toys, fingers - “there are fingers, toes and tongues going everywhere...”

 

Gonorrhoea infections of the rectum, pharynx and urethra in same-sex male partnerships attending a sexual health service in Melbourne, Australia.

Gonorrhoea within individuals, with same day testing of partner revealed the following results:

34% rectal infection,

22% urogenital infection,

7% throat infection.

Of those with throat infection:

60% of partners had anal infection, but wearing condoms or not for insertive anal sex did not affect the likelihood that their partner would have anal gonorrhoea.

21% of partners had throat gonorrhoea.

23% of partners had urethral gonorrhoea.

80% of throat gonorrhoea is missed on culture compared to NAAT.

Throat gonorrhoea spontaneous clearance rates are high.

Urethral gonorrhoea incubation period is only day(s) before it becomes symptomatic, whereas pharyngeal infection often remains asymptomatic.

 

Front-to-back wiping and dabbing wiping post-toilet significantly associated with anal neoplasia & HR-HPV carriage in high-risk women.

Women comprise the largest number of anal cancer cases. Why?

Women with a previous HPV-mediated gynecological cancer were studied.

Risk factors identified were: older age, inflammatory bowel disease, active and passive smoking, autoinoculation by front to back wiping.

Highly robust association found with all.

Dabbing showed a protective effect.

 

The changing pattern in sexually transmissable infection and HIV diagnoses in New South Wales publically funded sexual health clinics, 2010-2014.

HIV/STI testing and treatment is mostly done in General Practice.

Which ones are managed in public clinics?

Looked at chlamydia, gonorrhoea, infectious syphilis, and HIV.

Infectious syphilis and gonorrhoea are increasingly diagnosed in public clinics.

Gay men contribute highly in the proportions of infections.

 

The molecular epidemiology of Neisseria Gonorrhoeae in New South Wales in 2012-2014.

Increasing notification rates of gonorrhoea in females.

Is there an association in infection with particular genotypes vs gender (heterosexual networks vs MSM transmission)?

This study did in fact suggest that there is increasing infection rates within heterosexual networks.

 

Injecting drug use is associated with high risk sexual practices and sexually transmitted infections in gay men.

STIs and injecting drug use.

Less attention paid to injecting specifically in published studies.

Injecting drug use noted in 3% of HIV negative persons and 14% of HIV positive persons.

Non-injectors’ rates of chlamydia, gonorrhoea and syphilis were stable from 2010 to 2015

Rates with injecting drug users were tripled in all three infections over the same period.

Sexual networks in these men are key.

Injecting drug users need screening for these infections as a priority.

 

Higher STI yield among asymptomatic gay men attending a community-based shop-front service compared with a fast-track sexual health clinic service.

Community-based vs clinic-based asymptomatic STI testing centres for GBMs.

The overall results were twice the STI yield in the community-based vs the traditional clinic-based testing centres.

Highlights the importance of introducing more community-based testing centres.

 

Is the increase in syphilis notifications in Victoria due to increased testing?

The rates have nearly doubled in the last 12 years.

Analysed around 30% of the reported syphilis cases from 2012 to 2015.

Around 40% of GBM are tested for syphilis.

80% of syphilis is in gay men.

40% is in HIV positive gay men.

The increase in the proportion positive was much greater than the increase in testing.

With the advent of PrEP, this can only get worse.

 

Gonorrhoea positivity and risk factors among Aboriginal and non-Aboriginal women attending sexual health clinics in Australia.

Gonorrhoea in Aboriginal and Australian-born non-Aboriginal women.

Publicly funded sexual health clinics.

33,000 women were tested, 1.8% tested positive.

Aboriginal women were 3.5 times more likely to test positive.

Multivariate analysis highlighted strong association with chlamydia coinfection, remote areas, and age 16-19.

There was a slight increase in rates over time in non-Aboriginal women.

 

Gonorrhoea among males in Victoria, informed by the Australian Collaboration for Coordinated Enhanced Sentinal Surveillance (ACCESS).

The power of ACCESS in giving important information with a wide range of surveillance data.

This study looks at gonorrhoea tests in men over time.

Testing has increased.

Rectal testing among men has increased.

Pharyngeal gonorrhoea is an important reservoir of infection, data is available, and will be presented shortly.

Although laboratory data looks crude, there are lots of things we can link in with it.

 

Pro-active follow-up of victims of sexual assault: an initiative to improve medical care in inner Sydney.

A novel approach to follow up of sexual assault victims.

Medical follow up following sexual assault is generally low.

Individually phoned by a counselor and history taken.

Mostly women.

60% suffered vaginal assault, 12% anal assault, 1% oral assault.

2/3rds attended for assessment.

At initial visit, STI detection rate > 10%.

At 2 week visit, 5.6% had STIs detected.

Posted by on in Workforce Development

I have a couple more blogs planned from the excellent Hepatitis session on Friday that I should get done on the flight home depending on sedation titration but I wanted to take the opportunity before I leave BCN to thank ASHM for the sponsorship. It has been a great meeting of great educational value that will not doubt translate to better patient care.I hope you also found my blogs of educational value
Special thanks to Levinia Crooks and also to Samantha Williamson for the logistics.

Lastly, it is a long way to fly but sharing the cabin with the Stenmark twins certainly helped:

b2ap3_thumbnail_Twins.jpg

#22hourstarebear

Dr matt

Tagged in: EACS2015
Twitter response: "Could not authenticate you."