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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Day 1/ Monday 14/11/2016 - Highlights from day 1:

Today was full of diversity in Sexual Health Field.

It was amazing to see so many people come together to listen to each of the incredible presenters and discuss, debate and learn.

My main contributions today where through regular 'tweets' on my Twitter account.

Please check them out at Twitter @paulafe2

 

 

 

Sexual Health Day 2 Mycoplasma Genitalium

Mycoplasma Genitalium has a high prevalence within the community, is difficult to test for as well as being tricky to treat.

Mycoplasma his the cause of significant pathology including intrauterine death, PID, proctitis, cervicitis and urethritis.

Traditional treatment has always been 1g Azithromycin however there is significant emerging macrolide resistance. This leaves only Moxyfloxacin which is hard enough for me to get as a GP and Pristinamycin currently needing to be imported from France...

As reported we clearly need better testing that includes resistance screening as well as new antibiotics to target this insidious infection.

Mycoplasma Genitalium has certainly been a "theme" at this event and will be a a big part of future work. I have to wonder if MG infection may have been responsible for the many cases of "sterile prostatitis" I have treated over the years...

Watch this space.

 

Day 2 started off really well with a great presentation from Rebeca Guy, Associate Professor, The Kirby Institute, UNSW, Australia about using New Technology in STI clinics.....IT! Young people have access to IT 24/7

Basically, when someones at risk of an STI, they want an appointment ASAP so why not use electronic self registration and appointments, they can then use a computer assisted survey instrument (CASI) to input their sexual history = cuts down time, avoids awkward questions and more honest answers are given!

CASI can also be used for self collection of samples with Enrolled Nurse staffing = increase in clinic capacity, halves waiting time and process, therefore more clients seen!

In GP clinics there's a problem with low rate of Chlamydia testing in 15-29 years. Studies show that 73.4% of CT cases are asymptomatic and are attending the GP clinic for a non sexual health problem! Computer prompts could help and in a trial of 68 clinics using computer prompts there was a 30% increase in testing!

Having these computer prompts for STI screening can also be helpful in Aboriginal Adult health checks = 10% +ve STI's found using very little resources.

SMS reminders for treatment and recall in remote areas = quicker and higher numbers treated. Also SMS reminders for TORI /POC shows 64% of clients attending for recall but only 30% without SMS reminder.

Point of care technology gives results for CT/NG in 90 minutes, with high accuracy = quick treatment

Websites such as "Let them know" allow clients to notify partners by SMS, email, letter and has high usage, around 20,000 SMS's sent/year.

Online education can be used for parents and kids.

When a 2013 study asked secondary school age kids about reasons for not using condoms, one of the answers was "sex just happened and we didn't have a condom" But there's even an APP for condom delivery! Mind you it takes 1 hour and costs $15!!

Online resources for meeting people like Tinder would be a great opportunity to provide information on STI clinics, where to get tested, postal test kits etc

I'll definitely take back some of these ideas to Sexual Health Quarters in Perth (SHQ) especially CASI which would be so good to use in our extremely busy drop in STI clinics.

 

Great session today on rectal Chlamydia today that will definitely change the way I practice.

Rectal Chlamydia can be difficult to treat with increased resistance to Azithromycin (1g stat dose = 86% cure)...

99% cure has been noted with Doxycycline 100mg BD for 7 days.

Question is should this change my practice?

For me the answer is perhaps..

If compliance is an issue it may be best to do 1g Azithromycin and then test for cure. Have Doxycycline in backup for failure.

In severe symptoms and/or the patient is likely to have good compliance I thing I will change to the Doxy regime, also with test for cure...

 

 

Posted by on in Public Health and Prevention

Plenary 2 Tuesday 15/11/2016

GOLLOW LECTURE :Rebecca Guy Assoc Professor Kirby Institute:surveillance,evaluation and research program

Presented new technologies for STI  Prevention

Re thinking Sexual Health 

And how can we use new technologies for disease prevention

Specifically Information technology

To embrace what people are using therefore currency

In a world open 24 hours

 

Primary and secondary prevention:STI testing and diagnoses

What technology has been evaluated

PROBLEM: STI Testing;time consuming/registration 

Solution electronic client self register:self appoint

Outcome evaluation significant benefit re time saved

Problem of awkward conversations 

Solved by computer assisted survey instrument (CASI) 

Linked with management system

Evaluated as efficient, acceptable,

Problem of STI test with clinic capacity

Solution Xpress clinic

Evaluated 

All leading back to reflection and constant need to improve efficiency of practice and improved outcomes for clinic and client

GP still low STI  testing rates despite 80% young people go to GP

Latest findings suggest poorly targeted

ACCEPT survey:

150 GP clinics

73.4% of chlamydia presentations asympto clients attending for non sexual health issues /missed opportunistic test

.? COMPUTER PROMPTS 

Evaluated and helpful 30% increase testing

Need comprehensive screening eg previously rectal swabs not done MSM

User friendly software

Low Syphilis   testing in increasing STI rates

Solution:opt out/opt in syphilis test in HIV management

Simple cheap study in 2007 by DR Melanie Bissessor and MSM with HIV

Simple sticker on file requesting syphilis check

Pre 21%

Post 85% :such simple cheap intervention.

Study 2

Syphilis testing same day as HIV VLautomatic,could deselect:

Colaboration required clinics, labs under Burnett Istitute

ACCESS checks how tracking

Generally need to increase testing rates

Problem of treatment delays especially Remote areas

Discussed SMS reminders recall possibilities

TTANGO (test treat and go);Colaboration 12 Health Services

Key message is the mean time to treatment

With POCT 4/7

Lab test 19/7

And partners to be treated

Use of "Let them know"websiteMSHC, evaluated/acceptable:SMS

BUT people not returning TOC, reinfection and dangers PID etc

Discused other clinical strategies and efficiency eg: REACT RCT:

Not suitable for test kits mailed to address parents,partners

Other technologies not comprehensively evaluated

WA online educational resources parents and adolescents

Poor condom use reported: Adolescents report "no condoms it just happened"

The new world of online websites to meet and connect and how to tap into that population group to encourage testing

The difficulty of behavioural interventions

Technology must help research ,rapid info to inform  progress

data.kirby.unsw.edu.co JUST released

TAKE HOME MESSAGE

Why not all Health Services using IT/online technologies 

Is the future online Sexual Health Services.......

Need to all look at improved, efficient, acceptable and cost effective ways of increasing comprehensive STI I testing

 

Christopher Fairley  MSHC presented

The use of nformation technology to improve Sexual Health care in a following session

Which complimented Rebeccas presentation

Great comment; Health care is most important fight against STI

STI easier to control than treatment

Sexual Health does not deal with "noble organs" does not attract the $

need to be more efficient....like the Banks....

Need IT in clinical services

CAS:I :all staff  and clients love it

Use of SMS

Websites like Let them know

STI Atlas

Whats PREP

DATA OPENS EYES

CLINICIANS NEED TIO UNDERSTAND DATA

NEED A DATA BASE

 

Sexual Health Day 2 Pharyngeal Gonorrhoea

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

Professor Mark Hayter University of Hull

"Stronger Than The Sum Of Our Whole"

Notes: 

  • The one stop shop can be a great opportunity to offer comprehensive care for clients with multiple needs.
  • Great chance to consider combining sexual health and reproductive health, sexual health and drug and alcohol services.
  • Colocation within schools may be useful and a great chance to "be where the market is". Evidence points to importance of need for concominnent quality sexual health education as well as branding as "health" service rather than "sexual health " service to reduce stigma.
  • May not apply to all markets, ie gay men appear to prefer traditional GUM/Sexual Health services.

Personal reflections:

My question is, isn't the GP in the perfect position for this? I wonder if there are GP's similar to myself who feel strongly to be able to step up and provide these levels of services. 

Currently this reflects my own practice however I wonder if there are other GP's who have similar passions.

Will these services limit communication between teams and loss of some patients to primary care?

 

Sexual Health Conference Day 2  Gollow Lecture IT and sexual health

Notes: 

Young people are very engaged with new technology. 

  • It's available 24/7
  • Offers privacy
  • It can be interactive
  • Is able to offer sexual content.
  • For me it's highly valuable for education

New self check in stations have proven to increase efficiency with faster interactions, data being more accurate as well as allowing more patients to be seen.

Other interventions include medical software prompt systems which have proven to increase opportunisitc testing of STI's such as Chalmydia.

Computer system grouping of tests and guidance has also increased syphilis testing in HIV positive clients and checking for missed tests such as rectal swabs for Gonorrhoea / Chlamydia in MSM.

SMS recall systems have increased testing regularity and recall for test for cure.

Resources:

http://amaze.org
http://data.kirby.unsw.edu.au

 

Monday 14/11/16 – Day 1: Jan Edwards Trainee Session

Dr Danae Kent, Senior Registrar at Adelaide’s Clinic 275: ‘Testing for Rectal Chlamydia in Women – Is It Worth It?’

In short the answer was yes…and no! 

Rectal chlamydia infections in women have the potential to result in significant morbidity and enhanced HIV transmission. 

Few other Australian studies have looked at this topic.  The estimated rectal CT positivity rate in women is 5-27% (variable depending on population eg. higher in sex workers and sexually adventurous females).  Awareness of site of CT infection is important as this has implications for choice of treatment (rectal CT treated with Doxycycline vs genital CT treated with Azithromycin).

Method:

This South Australian retrospective study looked at women who received anal CT testing if they reported anal sex and/or anal symptoms.

Results:

Overall CT positivity rate = 8.5%

Young women less likely to have anal CT testing done but more likely to have positive anal CT result (of those with a CT positive result, 16% of women <20yrs were positive for anal CT)

Isolated rectal infections:

70% were found to have urogenital AND anal CT

19% were found to have rectal CT only

11% were found to have urogenital CT only

Therefore urogenital testing alone would miss 1 in every 5 cases of chlamydia confirming the value of testing for anal CT where a women reports anal sex and/or anal symptoms.  These findings are not generalizable to settings outside the sexual health clinic. 

Interesting food for thought and also a timely reminder of the importance of a thorough sexual history for the female client including enquiry about anal sex practices.

 

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. 

Notes:

Family Planning Victoria have had a large push to help create resources to help youth engage and navigate sexual health services and education.

Through alliance with schools, medical teams, educators the moderation and creation of resources has been helpful in engaging youth.

Resources can be reviewed at rse.fpv.org.au

There is very little in the way of research into non heteronormative society in indigenous and TSI communities. Sadly the majority of portrayals are hyper sexualised and not representative of diverse gender queer indigenous community.

This is a need to understand that "gay health" is not exclusive to "sexual heath" there are many more areas of gay male health to be explored and engaged.

Many GLBTI youth are suffering significant prejudicial treatment within the schooling system. Schools without GLBTI policy have increased self harm, suicide, bullying and harassment of GLBTI youth. 

GLBTI policy has been shown to be protective creating increased safety as well as retention in the school system.

Many trans and intersex youth are leaving schooling rather than face the poor treatment while attending school. Trans and intersex youth are at higher risk of self harm, suicide, and bullying.

Many resources provided at schools are not inclusive and not helpful or supportive for GLBTI youth.

Current estimates are that 2 in every 30 students are GLBTI and without inclusion they can be lost to schooling, bullied, self harm and be at risk of attempted and completed suicide.

Notes:

HPV associate with 90% of anal cancers. HPV 16/18 is associated with 92% of the HPV related anal cancers.

Being an MSM associated with a 40x risk of HPV anal cancer. Being an MSM who is living with HIV shows an up to 100x risk of HPV related anal cancers. 

Spanc study showed that while a percentage of men with self clear of anal HPV infection this is less likely with HPV 16 infection.

Despite treatment guidelines not recommending HPV vaccination in men older than 26 the SPANC study showed that many older men have not been exposed to HPV 16. This opens the suggestion that vaccination with 9 strain HPV vaccine may offer benefit beyond the age of 26.

The indigenous population of Australia is suffering with disproportionate levels of STI's. Risk are 3x for Chlamydia, 18 x for Gonorrhoea, 4x for Syphilis. Barriers have been identified for men to get STI testing including lack of information as well as culturally appropriate male health workers to engage with clients for testing.

There has been a significant rise in Syphilis infections within Northern Australia's indigenous population. Rates are similar in men and women in the younger age group 15-29 years old. 

Given risk of congenital syphilis and intrauterine death a robust testing campaign has been initiated to test all women of child rearing age as well as intensive screening of pregnant women. 

Testing in pregnancy includes up to 5 tests during pregnancy and if a female has had a positive test she is then testing monthly till delivery and followed for 3 months post delivery to ensure no reinfections.

Notes:

Indigenous Australians have a disproportionally higher levels of Chlamydia and Gonorrhoea compared to non indigenous Australians.

Point of care testing for Chlamydia and Gonorrhoea in Remote North Australia has proven to be highly effective in ensuring rapid diagnosis and treatment of those infected.

POC testing has reduced time to treat from average of 19 days down to 72% less than 3 days and the majority treated in under 7 days.

Real time testing of Ciprofloxacin resistance in Gonorrhoea is emerging with testing for genetic patterns associated with Ciprofloxacin sensitivity as well as resistance.

Pristinamycin is a novel new antibiotic with dual action that may prove to be helpful in treating macrolide resistant Mycoplasma Genitalium. In doses of 2- 4 g daily it has shown 75% cure rate in previously failed treatment of MG. Pristinamycin has shown an acceptable side effect profile and safety in pregnancy when given unknowingly.

New PCR test kits are emerging that allow the detection of MG resistance detecting 5 different genetic markers. This may aid better directly therapies for treatment of MG.

Changes in vaginal microbiota have been associated with increased risk of bacterial vaginosis.

Risk factors include, reduced levels of lactobacillus, increased exposure to different vaginal flora via new sexual partners, high levels of Gardinerella as well as changes in stability and increased diversity of the vaginal flora.

Female partners of men diagnosed with pathogen negative non-gonococcal urethritis should be notified, tested and ?treated with review of partners data showing increased rates of symptoms in female partners (60%) and a 12% association with PID.

Gemma Sharp from the School of Psychology, Flinders University,S.A talked to us about the project she's involved in looking at Labiaplasty. I found this really interesting but results were pretty predictable.

She told us it's the most popular form of genital cosmetic surgery and Australia has seen a 3-fold increase from 2000-2014. It involves the reduction of the labia minora.

She was looking at the factors that motivate women to undergo labiaplasty and the psychological outcomes using two studies.

In study 1 (qualitative study) She interviewed 14 Australian women 5-16 months post surgery and identified five themes:

1 Media influence - comparing themselves with online genital images

2 Negative comments about genital appearance

3 Physical discomfort over aesthetic concerns

4 Satisfaction with surgery

5 Sexual wellbeing

86% of the women expressed concerns with labial appearance, large labia impacting their sex lives and feeling ashamed about how their labia looks.

After labiaplasty 71% of the women stated an improvement in self- consciousness, feeling more comfortable having sex and feeling more free. But 29% still had concerns after labiaplasty. 

She concluded that psychosexual counselling might be an option for these women.

In study 2 (quantitative study) she looked at the effects on intimate relationships and psychological well being, using 29 labiaplasty patients compared to 22 general gyne patients.

She found that overall the labiaplasty patients were satisfied >80% and only 35% reported complications (infections/severe discomfort) but there were no significant changes in relationship quality, sexual confidence, psychological distress, self-esteem or life satisfaction.

She concluded that although labiaplasty improves genital appearance, it has no effect on psychological factors and preoperative relationship status and psychological distress predict dissatisfaction with outcomes.

Again she thought it was important to think about psychological treatment.

 

Amber D'Souza, Associate Professor, Johns Hopkins Bloomberg School of Public Health, USA gave a fantastic talk in the opening plenary today in Adelaide.

She talked about HPV causing >5% of cancers worldwide, >600,000 globally mainly cervical cancer.

12/100,000 - Cervical

8/100,000 - Oral

2/100,000 - Anal

She told us that the uptake of the HPV vaccine in Australia is 71.2%, UK is 60.4% but only 33.4% in US were there is no school based program and in 2014 the vaccine was available in over 75 countries but many low income countries are still missing the vaccine program.

Interestingly in the US they've seen a growing number of HPV positive oropharyngeal cancers especially in men. 2.4% per year in men 45 years and older but only 1% per year in women 45-64 years but all other head and neck squamous cell carcinomas have reduced ?due to reduction in smoking.

She said the lifetime risk of oral HPV infections in men was 3-30% but only 1-8% in women and one of the reasons why could be that cervical fluid has a higher viral load than the throat?

Risk factors were recent oral sex in last 3 months and the risk increased if the man had performed oral sex on a woman rather than a man. But interestingly, HPV is low in lesbian women which suggests that women get an auto immune response to previous HPV infections.

Gender - there is a 5 fold infection rate in men compared to women.

Race - HPV is higher  in white men compared to black or Mexican American men, does this mean that white men have more oral sex?

So with the same number of lifetime partners, men have a higher risk of orophryngeal HPV and a lower rate of clearing the virus.

Then she told us about Anal cancer that effects 2/100,000

Risk factors include receptive anal sex and in MSM 10-20/100,000 are +ve for anal HPV, that number is higher in HIV+ve MSM and these figures are increasing by 4-5% per year in US and Australia

Clearance usually takes 1-2 years 

She then went on to talk about the effects of HIV on HPV were the acquisition of HPV is higher in anyone with immuno suppression and clearance is less likely. The rate of HPV in people with HIV is 60%

In 2001-2005 29% of men with anal cancer also had HIV, making anal cancer the 4th most common type of cancer in HIV +ve men 

She summarized by saying that the changing landscape of HPV and related diseases needs to focus on prevention and screening for HPV DNA.

 

Stand out message regarding Non-Gonococcal Urethritis in men and whether their female partners need to know

Great first day at the 2016 Australasian Sexual Health Conference in Adelaide!

Something that stood out for me today was a study conducted about whether female partners of men with non-gonococcal urethritis (NGU)should be contacted, examined , tested and treated.

The answer was YES. 

Female partners of men with NGU have an increased chance of developing symptoms of Pelvic Inflammatory Disease (PID).

Some women report deep pelvic pain, post coital bleeding and/or burning on micturition as symptoms.

These women should be treated as for P.I.D. (important to rule out Bacterial Vaginosis at the same time)

Clinicians should consider the increasing evidence of Mycoplasma Genitalium (MG) resistance to Azithromycin and consider a 7 day course of twice daily Doxycycline 100mg po.

 In my experience, Doxycycline is not very well tolerated in a large number of patients. Gastrointestinal side effects and problems with photosensitivity are some of the more common side effects. In remote settings, would clinicians rather treat with Azithromycin 1g po stat on day of consult, examination and testing? 

I would love to know what others think about this.

 

 

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

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