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.

Subscribe to this list via RSS Blog posts tagged in 2016 Austalasian HIV conference

Dr Jason Ong:Monash Uni,The Alfred,MSHC

On Prevention of Anal  Cancer in Gay and Bisexual men:the current state of play and future directions

Excellent series of sessions

This session highlighted that we must reflect on some of the changing practices of rapid testing ,increase testing ,self  testing and remember the need for clinical examination also: LOOK

HPV VACCINE :THE GAME CHANGER

But a cohort has missed out

Do we adopt cervical screening protocol and do "chap smears"

Highlighted the key difference with anal Ca and cervical Ca although both SCC

Anal pap larger area,harder to identify lesioms in a collapsing environment,

Differing natural history

Differing referral rates,massive need for HRA/not feasible

No one agees best approach

Still no proof treatment assists outcome

.?trace the 30% males with HGAIN

Need better ways to treat,more RCT havent the specialists

Greater than 50% Anal Ca externally visible average lesion 2.9cm HUGE

BUTLess than 10% HIV  MSM  have annual anal exam

Need early Ca detection model:less than 2cm lesion possibly just excision with no spread or sphincter involvement,no chemo or radiation

Implement anal digital

Based on Wilson and Jungner screening critera 

;"GIVING THE FINGER TO ANAL CANCER"his PhD title

Key findings ;all specialists think it is important to screen for anal Ca but arent doing it

www.anal.org.au/clinician MSHC;:

Annual DARE study and recommendations

Acceptable,minimal s/e

99% clients willing to have annual dare

Dare is cost effective,safe,acceptable

TIME TO Do DARE translating evidence into action

Summarised;

Screen for precursor lesions

Triage

RCT FOR DARE unlikely

Jason is running an educational session at the ASHM hub Friday

DO YOU DARE?

Timely as Tasmania Sexual Health are  fortunate to have Prof Richard Turner:Colorectal surgeon Royal Hobat Hospital/UTAS

Continuing his research with monitoring HSIL anal paps :HRA ,histology ?treatment for HIV clients and Women with HSIL paps

He has spent time to demostrate DARE  to all clinicians and advises annual DARE

The final session by Brad Atkins of his horror story of his  diagnoses and treatment of anal cancer and being totally uninformed and underprepared and to be reminded of the STIGMA,embarrasment people feel

Makes it urgent to "AT LEAST LOOK AND PUT YOUR FINGER IN OR YOU WILL MISS IT"

BACK TO THE BASICS.....

Notes from talk stream:

Men who have sex with men are at significant risk of HPV related anal cancers. HIV negative MSM are at an estimated 20-40x risk and HIV positive MSM are at 100x risk!

HPV Vaccination is going to be one of the keys to help reduce this risk.

Many gay men have not been vaccinated for HPV and this is a key move that can help reduce incidence.

Many doctors are not doing DRE to examine for any anal lumps.

It's a simple, cheap and easy exam and can detect early anal cancers from 0.5cm diameter.

Early detection <1cm results in simple surgical treatment that may not require chemo/radiation therapy.

HIV positive men should be offered annual DRE and HIV neg MSM every 1-3 years.

Anal Paps are difficult to fully roll out at the moment as many early anal changes will self regress. Sadly anal colposcopy services are very limited currently making this one area of bottle neck in evaluation of early anal lesions.

This session has absolutely changed the way I will be practicing and caring for my MSM patients from today!

Good resource for futher information for both doctors and clients is this site created by AFAO.

http://www.thebottomline.org.au

Divergence in HIV rates within Aboriginal and Torres Strait Islander communities in Australia

Wednesday 16/11/2016

A/Prof James Ward spoke about the divergence of HIV rates within Aboriginal and Torres Strait Islander (ATSI) communities.

HIV/AIDS in Australia has been a contained epidemic until now.

In 2015 Australia has seen the highest number of notifications in ATSI patients on record since the numbers have been monitored.

This is almost double what the Non-Indigenous notification rates are.

The majority of notifications are in men who have sex with men (MSM) at 51%, then the Heterosexual population is 21% with IV Drug Users at 16% of the notifications. (this was previously 3% in the 'early days')

Reminder that these figures are already 11 months old. Timely surveillance data is crucial.

The rate of notifications in Indigenous females is three times the rate of that of Non-Indigenous females.

This has been high in all regions, not just the urban and inner regional areas but now in the remote areas.

A/Prof James Ward mentioned there are a number of reasons why divergence is occurring but highlighted a few of the main reasons to be:

- a young, mobile population in more regional and remote communities

- risky practices such as sharing injecting equipment and the high prevalence of sexually transmitted infections (STI's)

-there is a lack of needle syringe programmes in the remote areas.

-failure to engage TasP (Treatment as Prevention) and PrEP (Pre-exposure prophylaxis) in the communities

-there is a high burden of disease and multiple co-morbid conditions in the Indigenous population and often these patients are on a number of other medications

He stressed the importance of being inclusive of all vulnerable populations when it comes to HIV.

The high prevalence of STI's in the 10-24 yr old age groups increases the risk of HIV transmission and poses an ongoing problem.

Previously there has been an increased focus on suicide prevention in this age group which is very important and needs to be ongoing , however, with the current Syphilis outbreak in Northern Australia and increase in HIV notifications more efforts need to be made to tackle this problem.

Unfortunately there is inequity in service delivery to these remote communities.

If we take a closer look at the Syphilis Outbreak in Northern Australia, the numbers of infectious syphilis diagnoses have risen exponentially. 

Could we be dealing with a similar chart for the HIV increases in the near future? Are we prepared for this?

Using some figures from Cairns;

-prior to 2014 there were approximately 15 diagnoses of HIV with 1-2 cases reported in ATSI patients.

-from 2014-2016 the diagnoses of new cases in the ATSI population increased to 50% of the total number of cases.

Most of the cases recently have been in young men who identify as bisexual or heterosexual.

The recent high level summit report in Brisbane has highlighted what is deemed important in terms of tackling this problem in communities.

Workforce development is crucial. Downsizing in certain areas is disastrous as currently the Indigenous population is in the most vulnerable position regarding the HIV increases.

HIV needs to be managed in the Primary Care setting using the support from central public agencies to assist with management.

There needs to be outbreak management and community involvement at every level.

Some suggestions have been to make HIV testing within 30 days after a STI has been diagnosed a nKPI. (National Key Performance Indicator)

To make STI and BBV (Blood Borne Virus) testing compulsory linked to the Aboriginal and Torres Strait Islander Health Check. (Medicare Item 715)

To have Medicare Item numbers for STI/BBV testing.

Education with regards to health literacy is important together with rehabilitation programmes and opioid substitution therapy for IV drug users.

Post Exposure Prophylaxis (PEP)is misunderstood and the community do not know how or when to access this.

James Ward stressed that the community needs to be involved at the forefront of the efforts ,the community needs to be engaged.

I would hope that after attending this conference that all of us walk away with at least a few strategies to take back to our practices or organisations to help prevent HIV becoming an epidemic in the ATSI communities.

I found the presentation by A/Prof James Ward eye-opening and motivating.

We all have a responsibility to play in changing the course of the diverging HIV rates within the Indigenous population.

 

 

 

 

 

 

 

Posted by on in Testing and Treatment

Encouraging people to test for STI, is an ongoing issue for all health services. These three posters trialled different ways to increase testing, with varying results. SMS, parlor and ads via websites proved the least effective, while pop-up at community events was effective and highly acceptable.

 

Evaluating the impact of Grindr advertising on website traffic and HIV testing at a regional sexual health clinic Lead author: O'Reilly,M. et. al.

This poster looked at the effectiveness of advertising on Grindr. It was found that a large number of people viewing the website clicked on the ad, however it didn't translate to visitors to the clinic.

The conclusion was that they redesigned their website to make online bookings easier and are exploring other ways to increase visitors to the clinic.

Pop-up Rapid HIV Testing at Community Events: expanding the PRONTO! Testing Model! Lead author: Ryan, K.E. et. al.

They explored the uptake, acceptability & development of pop-up HIV testing via field notes and client surveys. 

After 78 tests, 98% of respondents reported being likely to test again at community pop-up events. 22% had no previous HIV test. 

Pop-up testing at community events was successful and highly acceptable amongst those surveyed and will be used at future events.

Intiatives to Improve Sex Worker access to STI screening in Sydney Local Health District: Lead author: Hatten, B. et. al.

Two methods were used. The first was SMS messaging to send reminders to sex workers to encourage them to have their scheduled 6 monthly testing. The second was offering testing in a parlour setting.

Both methods were found to not significant impact the rates of testing. 

Posted by on in HIV Cure, eradication of HIV

Brent Allan spoke on the jading effect he feels, with the constant media reports of HIV "cures". He started by asking for a show on hands, to indicated how long it would be, before a cure would be available. The majority of the audience voted for 10-15 years.

He read several headlines from news report, published in the last week. These included "Cairns to trial HIV drug cure" which turned out to the trialling of PrEP. Unfortunately most of these headlines were from respected news agencies, which generates online discussion and the resulting analysis has a demoralising effect.

Brent also identified the need to provide hope for newly diagnosed HIV, even with these headline grabbing misinformation.

The session ended with an interesting question to the audience. If we expect a cure in 10-15 years, then what are we doing to help people living with HIV to transition to life without HIV? As positive as living without HIV sounds to me, for some who have lived with the virus for 20+years, they may lose their identify. 

All things PrEP (courtesy of Prof Jared Baeten)

I haven't come across PrEP before - it is not easily accessible in Western Australia, although a few patients have obtained it through personal importation.  Hence, the sessions on PrEP were of particular importance to me as I'm sure they will be filtering through to WA very soon.  In particular I enjoyed the summary by Prof Jared Baeten, and I've tried to summarise my learning points below.  I've combined two of his talks into one.

 

Firstly, I love this quote that he put up (forgotten who said it though): all truth goes through three phases: it is ridiculed, violently opposed, and then accepted as self-evident.

 

  • PrEP works: those who had tenofovir in their system had a >90% reduction in HIV transmission
  • PrEP works for high risk patients
  • a single agent may work as well as dual agents (e.g. TDF only = 85%, TDF/FTC = 93%)
  • adherers adhere
    • not everyone used PrEP, but those who did use it tended to be consistent users
    • non-adherers rarely started adhering
    • there wasn't much change in behaviour after 1 month
  • surprisingly, real world effectiveness was better than efficacy in the studies
    • ?adherence was better in real life than in the trials
  • PrEP  has several additional benefits
    • decreased anxiety
    • increased communication and trust
    • increased sexual pleasure and intimacy
  • chance of developing eGRF <70 while on PrEP if your baseline is >90 is extremely small
  • rising STI rates in the US have been happening for a while, even before the introduction of PrEP
  • PrEP works even when STIs are present

 

Most of the informal feedback I've heard before today has been that PrEP is associated with an increase in STIs but if the data above is applicable to Australia, then perhaps that isn't quite true.  I think the evidence if favour of PrEP is mounting, and the major obstacle in Australia is probably the cost-benefit ratio...

Divergent rates of HIV in Aboriginal and Torre Strait Islander

Dr James Ward gave us a thought provoking opening speech outlining the recent increase (i.e. divergence) of HIV infection rates among Aboriginal and Torres Strait Islanders compared with the general population.  Here are the take home messages from the talk:

 

  • initially rates of HIV infection were similar between Indigenous and TSI, but numbers are now increasing
  • 2015 marked the highest rate of new diagnoses (n=38)
  • new diagnoses of HIV are occurring in rural and remote areas, which has never been seen before
  • why?
    • background: young, more mobile, more regional
    • risks: injecting equipment, high background of STIs
    • success in non-indigenous diagnosis
    • failure to engage with community
  • how to improve?
    • increasing workforce rather than downsizing
    • timely surveillance data (absurd that we deal with 2015 data in Nov 2016)
    • implementation of a national KPIs reportable for STIs by Aboriginal PHC
    • change to AHC, make STI/BBV checks more mandatory
    • Medicare items specific to BBV/STIs
    • improved testing strategies
      • only 32% of people with a positive STI screen had an HIV test within 30 days

 

I found the session a real eye opener and saw that there were plenty of areas that we could improve in. Simply increasing the rigor at which we conduct testing would seemingly make a big difference.

Posted by on in Uncategorised Posts

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

 

 

 

Posted by on in Testing and Treatment

This was a sponsored satellite symposium, held at the ASHM/Sexual Health conference. It consisted of a panel discussion which was chaired by Dr Norman Swan.

The question posted was- Can Australia be Hep C free by 2026? The short answer is....possibly.

Back ground

Hep C eradication treatment started this year. 20,000 people have been treated and by the end of this year 45,000. The bulk are patients were keen for treatment. Currently 82% of people with Chronic Hep C in Australia, have been diagnosed. This leaves 22% diagnosed. There is a dis-proportionally higher prevalence in the indigenous and incarcerated populations.

Resistance to treatment

Concerns remain in co-infected patients, that eradication treatment is difficult or may impact their HIV.These concerns linger from previous Hep C eradication treatments. They don't translate to the new treatment.

There are some drug interactions between ART and Hep C eradication treatment, however these can be managed.

Attitude change

An attitude change in government, patients and health care providers is required, to identify the remaining 22% of undiagnosed patients. This is needed, as without a significant reduction in Hep C in the general population, reinfection may occur. Re-treatment will then be required, and should be offered.

Hep C resistance

This has already occurred and needs to be avoided. Ways to prevent resistance is discussing with the patient to determine if they can access and afford the medication, for the entire treatment course. A wavering of the cost of opioid replacement therapy, needle exchange in prisons, nurse practitioner to subscribe treatment and patient education on preventing reinfection, will also contribute to preventing resistance.

Take home message

The uptake of Hep C treatment has been fantastic. Limit the opportunity for resistance by reducing the opportunity for partial treatment. Educating patients on preventing re-infection. Identifying patients who may have Hep C but never tested.

If this treatment to work, then we (and the government) needs to approach this treatment, like the Small Pox Eradication Program.

 

 

Amber D'Souza outlined the epidemiology of anal cancer pointing out the significantly elevated risks for HIV positive MSM. She found DARE acceptable to patients within a study of 327 men.

Dr Jason Ong posed the question "What should we be doing with our patients now?"

He gave compelling reasons to screen for anal cancer targetting the most at risk, that is HIV positive men > age 50 ideally with an annual digital rectal exam to try and detect anal cancer at an earlier stage than is currently achieved with reactive checks related to symptoms.

50% of anal cancers are visible externally ie just looking would make a huge difference and currently less than 10% of HIV positive MSM have annual anal exams.80-100% will be found with DARE.

It is a simple safe cost effective and acceptable practice and can lead to better outcomes.

The evidence for screening for precursor lesions seems less compelling. 

HSIL is present in 30-50% of HIV positive gay men however only 1/400 progress to cancer in HIV positive men and 1/4000 progress to cancer in HIV negative men. 

SPANC has greatly increased understanding of this process.?Highest risk to progression to anal cancer is seen in those with persisting HPV16.

It was also suggested by Jason and Dr David Templeton to consider HPV vaccination in this group as despite the lack of evidence for efficacy, it may work.

From positivelife NSW we learned that most PLHIV  thought their risk for anal cancer was the same or lower than the general population.

84% of respondants in that survey and 64% HIV respondants had never talked to thier doctor about anal HPV/cancer- we should clearly be doing better than this.

As PrEP has now been used in the USA for about six years, Dr Jared Baeton compared PrEP to the developmental milestones reached by the average six year-old child.

 

  1. At six years old, we begin to understand cause and effect relationships.

    1. If you take PrEP, it works. As in, if you have good adherence, then it is close to 100% effective at preventing HIV transmission. Interestingly, studies have shown that those individuals at greatest risk of HIV appear to have a greater HIV risk reduction from PrEP. This suggests that those individuals at greatest risk of HIV also have the greatest adherence to PrEP.

       

  2. At the age of six, magical thinking fades quickly: PrEP is not perfect, and PrEP does not expect us to be perfect.

    1. PrEP is not perfect, but PrEP is safe. We have good data on kidney safety and bone safety for PrEP users. Also the risk of antiretroviral resistance appears to be limited to those who start PrEP in the context of an acute HIV infection, rather than those who seroconvert during PrEP use. He did not further expand on this thought, but perhaps those who seroconvert during PrEP use have such low adherence to PrEP that it does not result in the selection of resistant HIV variants.

    2. PrEP does not expect us to be perfect. In clinical trials, not everyone used PrEP, but those who did use it tended to be consistent users (Partners PrEP). Those who were not adherent at one month tended to never become adherent. Dr Baeton drew an analogy between PrEP adherence and flossing: Some of us floss every day, and tend to continue doing so, others rarely floss and never start flossing regularly.

       

  3. The average six year-old starts to understand the feelings of others. As a medical community we’re starting to understand what PrEP users want out of PrEP. And PrEP use has been shown to be associated with:

    1. Decreased anxiey

    2. Increased communication, trust, and HIV status disclosure

    3. Increased self-efficacy

    4. Increased sexual pleasure and intimacy

 

Stigma remains a key barrier to PrEP use: This includes stigma about ARVs, HIV and stigma about being at risk of HIV.

4. Six year-olds become more flexible in their thinking:

  • Success in PrEP adherence is achieved when PrEP is used during times of HIV exposure, this has been referred to as “prevention-effective adherence”. I think we need to develop some clear messaging around “prevention-effective adherence”, to assist people in

  • STIs will occur in persons using PrEP. People who need PrEP are at hight risk of STIs.

  • PrEP makes us think very differenctly about three decades of fear-based public health campaigns.

 

5. 6 year-olds start to understand more about his/her place in the world. PrEP is not a panacea, but it has the potential to form an important part of the toolbox of HIV prevention.

 

I think PrEP has come a long way over the last couple of years, including in Australia. In order to continue this trajectory, I think we need ongoing efforts to:

1. Obtain PBS-listing for PrEP

2. Prevent the emergency of PrEP-associated stigma, by framing the discussion around PrEP in a sex-positive manner.

3. Develop clear messaging around dosing regimens that do not involve daily PrEP. Some people do not need to be on PrEP continuously, and we need to have realistic conversations how these people can effectively manage their HIV risk without necessarily taking PrEP every day.

With just over two weeks until the virtual 2020 Joint Australasian HIV&AIDS and Sexual Health Conferences, now is a… https://t.co/qdLZhBZgQ7

ASHM ASHM