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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Dr Marcos Davi G. Sousa Specialist in Infectology, Federal Hospital of the Servants of the State of Rio de Janeiro presented a case history of a male, unfortunately he didn't state how long the patient had been HIV +.

* 51 years of age

* COPD

* alcohol dependant 

* very poor ARVT compliance

He had previously been treated for Tuberculosis, mycobacterium kansasii and mycobacterium avium, but continued to experience poor health, and poor compliance on ARVT.

He was tested and treated for M. intracellulare in Jan 2015, then tested positive for "atypical mycobacteria" in Sep. 2015.

In Nov 2015 a positive culture identified M. colombiense, the first isolate of this species in Brazil. It is a slow growing  type of  mycobacterium that infects both immunocompetent and immunocompromised people and was first isolated in Bogota, Columbia in 2006. Importantly, infection can mimic tuberculosis.

Treatment provided was the same for tuberculosis and should have continued for one year after the last negative test, but the patient continued to be non compliant with treatment and apppointments. Resistance testing was not yet available, and the outcome for the patient was not presented. 

 

Posted by on in Public Health and Prevention

How do you summarise such a comprehensive and jam packed conference into one post?!

 I have been absolutely overwhelmed by the great presentations and seeing such wonderful colleagues from around the world share their research to everyone.

 Some of the main highlights for me were the Doxycycline as prevention plenary which had a great discussion post presentation from a lot of clinicians around the world, but overall good to see the willingness to possibly adopt a new strategy with condom-less STI prevention.

 I engaged in Twitter posts throughout this conference (NB: #stirio2017 was the second most trending tag in Brazil), which I noted was quite popular among a lot of speakers and presenters to share information back home. Even seeing some of my tweets liked or re-tweeted by people from BASH or the Lancet was great to see how quickly the sharing of information between colleagues can happen. This was an exciting approach to disseminating conference material for those who couldn’t attend.

 A common theme I found was discussions around the antibiotic resistance in Mycoplasma and Gonorrhoea, and how appropriate testing and prescribing practices, specifically around not using Azithromycin with rectal chlamydia are really important to bring inline uniformity to treating as based on the WHO treatment guidelines.

 PrEP implementations are varied worldwide, and you can see how much funding and stigma around getting TDF/FTC out to communities is quite difficult in different political landscapes. There were so many posters presented and some great questions were posed around PrEP in relation to STI’s and Hepatitis C.

 One of the final presentations from Tetyana Vasylyeva (Ukraine) was quite moving considering the research was based on changing opinions on HIV prevention in the landscape of countries facing war. With a high amount of IVDU and a cut on all methadone programs at the time of the civil unrest in Ukraine, larger numbers of migration changes into already high prevalence areas without primary health resources, are increasing risk of HIV transmission.

 Currently in Ukraine they have over 220 000 known HIV + people with only 28% ARV coverage. Post war data showed over 1.7million people are currently displaced and with migration patterns changing, and cuts to public health funding this is making ARV programs difficult to sustain.

 I had hoped to catch up with Tetyana after the talk to ask more questions but like others, most people were running between rooms to catch different talks.

I've also attached some of the posters I enjoyed reading as well.

 I am so humbled and honored to have been selected as a scholarship recipient for ASHM, it has enhanced my knowledge significantly and after seeing a large number of clinicians in Rio, I hope further sexual health nursing members are able to attend in the future to bring relevant information back to their colleagues.

 

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Findings from the national online HIV self-sampling service in England. (Luis Guerra).

I found this talk to be if interest because in NSW we have launched the Dried Blood Spot - Home HIV self testing.

In England - eligible participants go to a website - WWW.freetesting.hiv and answer a. Few questions and then get a box sent the address they register.

The person then follows the instructions in the kit and utilising a lancet leaves a blood spot which is then posted back for testing.

Results are then sent out within 3 days via the delivery method the participant chooses.

If the result shows Reactive - the participant is contacted via phone and notified of the Reactive result - explaining the possible outcomes of a reactive result (Explaining it doesn't mean its a positive test).

The participant is given the details of local clinics and services and offered an appointment or they are able to book themselves.

Of the 40726 kits sent out - 22085 were returned. That's a 54% return rate.

There were 239 reactive samples.

Of those that tested 30% had never had a test. And 32% last tested over 1 year ago.

 

I hope that the NSW Dried blood spot testing program has such a high return rate and that we are able to capture the amount of people that otherwise would not have tested.

 

 

This morning I attended the Oral presentations for HIV/STI testing and management, looking at different studies around HIV risk.

Brendan Harney from Melbourne presented his study: Risk of HIV following repeat sexually transmissible infections among men who have sex with men in Victoria, Australia. 

This presentation was a retrospective study questioning, if MSM have repeat positive STI diagnoses, are they at an increased risk of HIV transmission? 

Out of 8941 MSM (median age 29, Australian born) surveyed at a busy Melbourne Sexual Health Centres, 2.5% were diagnosed as HIV positive.

Although repeat Chlamydia and Syphilis notifications were common, Rectal gonorrhoea was found to be the highest, with 13.5% of those with a repeat positive gonorrhoea rectal infection becoming HIV positive.

Conclusion? Repeat Gonorrhoea infections are strongly associated with a HIV infection, and that this data is key to looking at PrEP inclusion criteria and why we target specific groups and behavioural activities for PrEP enrolment studies. 

 

This morning I watched a presentation by Joshua Rosenberger (USA).Examining the role of STI prevention among MSM using mobile applications.

He was discussing a study that was conducted in a American city with a population of about 1 million people. Looking at how many MSM that logged into a particulat Geospactial networking app within a 24 hour period.

And where these men lived in relation to the Sexual health and HIV services that were available in the city. 

In a 24 hour period 5000 men logged into the Application. Most of the men being of white or Hispanic background and living in the inner city and downtown area. There was a population of African-American background that lived further on the outskirts of the city. The peak time for log on being 2000 through till 2300.

Using this information and location of the men that logged in they could see the centres for access (their clinics were all located in the city area). Which was great for the small population of white men that lived in that area. But not so for the rest of the population. Especially there most at risk men of African-American background. 

The clinic hours extended until 1730 at the latest. So how could they use this information for health promotion and to allow for better access to the rest of the population at greatest risk for STI/HIV prevention and education?

 

My Take HOME MESSAGE:

Harnessing the use of mobile application services is a great way to ascertain where the target population are living and using the platforms for advertising "Health Promotion".

In Australia and especially in NSW we have embraced Mobile Social Applications such as GRINDR to deliver Health promotion activites. But can we better utilise the data to look at where we need to direct outreach services to capture the proportion of the population that do not live in "The bubble" of the innner city - where a lot of our Sexual Health and HIV services are located. 

Today I watched Catriona Bradshaw (Monash University, Melbourne) present on M.G.

WOW. Great presentation.

M.G Slow to grow and difficult to culture. 

Looking at resistance patterns around the world its very clear that over prescribing of Azithromycin has lead to macrolide resistance in M.G.

Looking at countries that have prescribed STAT Azithromycin for NGU and now looking at resistance profiles its very evident that we need to change our thinking and prescribing.

Catriona showed the resistance profiles of two countries side by side - Sweden and Norway. One Country having used Azithromycin in NGU treatment and the other having used Doxycyclin. Very different results.

It made me think of the landscape in Australia - and the different drugs being used in current guidelines. Which I might add are always evolving with new evidence.

Russia has a low prevalence of resistance - Its not used Azithromycin.

Countries that have used Azithromycin in NGU have had an increase in resistance from 10% to 40% in 10 years.

Widespread use of Azithromycin for STIs and Syndromes has led to high failure rates for M.G.

Some regions already leading the way - U.K. And Europe changing guidelines to recommend Doxycyclin.

We need to move towards testing that can perform resistance testing so treatment can be individualised.  This will shorten the duration of infection, reduce transmission of resistant strains and recurrent clinical presentations.

 

 

My focus today was on Mycoplasma Genitalium as it has been a topic of many discussions recently. 

Several presenters discussed this topic

Dr Catriona Bradshaw, Melbourne Sexual Health

Dr Jorgen Jensen, Statens Serum Institute, Copenhagen

Prof. Charlotte Gaydos, John  Hopkins Centre

Dr Lisa Manhart, University of Washington 

Mycoplasma Genitalium (MG) causes symptoms similar to C. Trachomatis & N. Gonorrhoea 

Sequelae in women include pelvic inflammatory disease, spontaneous abortion, preterm birth and infertility. 

Diagnosis is limited to NAAT as culture lacks sensitivity and takes a long time. It is however recommended that NAAT testing should include resistance assay.

First line treatment regimes have included azithromycin and doxycycline, individually or in varying combinations, but doxycycline has a low efficacy rate and macrolide resistance has developed after 20 years use of azithromycin for other STI's. 

Moxifloxacin has been used as second line treatment but the past 10 years has seen emerging failure rates in some countries with rates as high as 15% in Asia-Pacific regions. Recent warnings from FDA and Europe, high cost and side effects make this option unpopular.

Funding for testing and trials of new classes of antmicrobials include

* solithromycin

* lefamulin

* diafloxacin

* zoliflodacin

* gepotidasin

The emergence of dual class resistance to both macrolides and  quinolones means there is no highly effective class of antimicrobials currently available to treat  MG. 

Prof. Basil Donovan from the Kirby Institute Sydney in his discussion of treatment of chlamydia, advocates for alternatives to azithromycin. This concerns me, as my experience in a sexual health clinic is that poor compliance is a major factor for using single dose treatments. I hope that new antimicrobial treatments will include single dose. 

 

Evolution and global spread of resistance in STIs- a very useful and insightful topic and very relevant working clinically in the field of STIs. 

The session started with Dr Magnus Unemo who presented ´Evolution and global spread of resistance in Neisseria Gonorrhoeae´. Antimicrobial resistance (AMR) has mostly emerged in post- modern times due to both SNPs and recombinations. Specific linegaes are more prone to develop resistance and remain susceptible.  Extended spectrum cephalosporin (ESC) resistance has emerged from Japan as highlighted in the paper by Shimuta et. al 2015 (BMC Infectious Diseases). Genotype 1407 has accounted for most decreased susceptibility to ESCs worldwide. Most microbial resistance is due to use or misuse of antimicrobials. AMR is a global concern requiring enhanced surveillance, need for new antimicrobials and development of a vaccine is crucial.

Dr Catriona Bradshaw discussed ´Evolution and Global Spread of Resistance in Mycoplasma Genitalium´.

Mycoplasma Genitalium (MG) is a fastidious and slow growing organism making NAAT the only diagnostic solution (difficult to culture). Treatment options are limited as mycoplasma lack a cell wall and are unaffected by many antimicrobials.

Doxycyline is used as first line treatment in many areas of the world but it exhibits low overall efficacy with cure rates of 20-40%. Azithromycin however is widely recommended as first line treatment but there has been a notable decline in efficacy over the past decade. Selected macrolide resistance has been demonstrated, at least 10% of the time following 1g of azithromycin. 

Widespread use of azithromycin for syndromic management of STIs has likely contributed to resistance. Prevalence of resistance is worse in the Asia Pacific region.  Prevalence of resistance to azithromycin appears to be less in countries that preference doxycycline for 1st line treatment of MG.

Moxifloxacin is most commonly used as 2nd line treatment in NG. The recommended dose is 400mg daily for 7-10 days. However in 2007 there were the first reports of moxifloxacin treatment failures for MG.

The experience in Melbourne has been a 12-15% moxifloxacin treatment failure rate. These treatment failures have been associated with ParC mutations. ParC mutations have been observed at low rates in Europse when compared to the Asia Pacific region.

What is concerning is that dual class resistance is emerging which will have huge clinical implications. The priorities now are review of using azithromycin for STIs and syndromal management, development of new antimicrobials and evaluating the use of exiting registered antimicrobials. This particular talk was followed up later in the day with a session from Dr Jorgen Jensen and a late breaker session which I will blog about later on. 

These particular sessions I feel were extremely worthwhile and will have a huge impact on clinical practice. It reiterated the need to be mindful of antibiotic prescribing and be aware of emerging resistance.

 

Posted by on in Testing and Treatment

I attended a lunch session sponsored by Cepheid regarding rapid STI diagnosis and use of point of care testing.

Working primarily in an Indigenous health setting in North Queensland I wanted to see whether a point of care testing model might be helpful with our patient cohort.

Dr Jeff Klausner started the session off presenting `Utility and applications of rapid, molecular STI testing in hard to reach populations´. The current STI statistics globally are quite staggering; over one million new STIs are acquired globally every day and each year there are 357 million new curable STIs ( CT/NG/TV and syphilis).  There is the rising risk of untreatable gonorrhoea, so much so that the WHO has listed NG as one of the top 3 infections that require immediate action. CDC reports demonstrate that STIS are increasing for the first time since 2006 and CDC STI guidelines indicate that treatment needs to be provided on the same day and directly observed.

Point of care STI testing clearly has demonstrated merit. For the patient it provides decreased anxiety and less patients are lost to follow-up. From a public health perspective there is decreased risk of forward transmission of infection, faster treatment for patients and their partners and decreased antimicrobial resistance. From an economic point of view there is scope to expand clinic capabilities, improve treatment costs and target individualized (rather than empiric) treatment. This was illustrated in the example of the Dean Street Express clinic in London. With the use of PoC testing there is quicker treatment, decreased waiting times and increased testing.

Dr Klausner discussed the rates of STIs in pregnancy and the negative consequences of STIs in pregnancy including miscarriage, stillbirth, preterm labour, low birth weights and increased MTCT of HIV. Currently only 13 countries in the world require routine chlamydia testing despite these known adverse outcomes. Point of care testing was trialled in 7 low-middle income countries and more than 2,200 pregnant women were screened for CT, NG and TV. The result of this trial showed high acceptability amongst patients and high treatment rates.

Dr Basil Donovan went on to discuss ´Implementing molecular POC testing in remote primary care in Australia´. Dr Donovan illustrated the difficulties of health care in remote Indigenous communities including the distance from laboratories, high mobility of the population, delays in time to treatment, high rates of PID and disseminated NG.

The Test, Treat and Go Trial was discussed (TTANGO). This was a cross over randomised controlled trial that compared traditional laboratory testing with point of care testing in a number of remote locations across Australia. Median time to treatment was 0 days for POC testing versus 7 days for laboratory testing. Patients reported that they liked getting their result on the same day, that they could be treated on the same day and that they didnt have to return for follow-up. The patient reported dislikes were that they didnt like ´waiting around´. Staff were also interviewed and expressed that they ´felt like a scientist at times´. The staff reported that the point of care tests were easy to use and interpret and they felt increased job satisfaction. Of course there are challenges to report which included high staff turnover in these communities, the need for ongoing public health surveillance and adapting clinical practice.

The session in my opinion was very useful and insightful and very relevant to my current clinical practice. At the particular indigenous health clinic I work at we have high rates of STIs, high rates of treating emperically and difficulty with follow-up. Point of care testing (if costs are appropriate) may be an option for our clinic to improve treatment rates and appropriate use of antimicrobials.

 

Does Doxycycline Prophylaxis have a future?

The short answer from Jeffery Klausner (UCLA, CA) is; Yes.

Jeffery spoke about the two studies and looked at those results.

Antibiotic prevention is nothing new; Rheumatic fever, travellers (Malaria), Lyme Disease, or Travellers Diarrhoea. 

With increasing Syphilis rates in MSM and the risk of facilitating HIV transmission, Doxycycline Prophylaxis could defiantly have a place.

As we already know, Doxycycline is a narrow spectrum antibiotic that is inexpensive.

Two RCT's were conducted; one study looked at daily 100mg Doxycycline for 30 men over 48 weeks (not behavioural intervention), on average most had 1mg/ml in samples with only a few having undetectable levels (?non adherence) which overall showed good levels.

  • 73% reduction in Syphillis
  • 70% reduction in other STI's (Chlamydia)

Study 2: On demand Doxycycline as PEP. RCT in HIV negative men on 200mg single dose up 24 hours after sex, maximum 72 hours post sex. NB: No more than six pills per week.

  • 70-73% reduction in Syphilis and Chlamydia infections.
  • No effect on Gonorrhoea. 
  • Noted increase in GI side effects, (nausea, GI pain and vomiting), nil adverse events.

Both studies showed great results, but more research needs to be done (Australia is part of a trial at the moment), and concerns around long term safety as well as ?Resistance (MRSA) were raised.

Overall a great presentation looking at the future of condomless prevention of STI's in a time where we have over 6000 MSM using condomless HIV prevention in NSW (EPIC, NSW)

 

Posted by on in Testing and Treatment

Gwenda Hughes (National Centre for infectious Disease Surveillance and Control at Public Health, UK)

Spoke about some STIs that are neglected or under tested for. Primarily she spoke about Trichomoniasis. LGV and Enteric Infections.

TV - Seen very rarely in Australian population - but are we testing enough? A large poprtion of infections are asymptomatic. With a higher prevalence noticed in African and black women in the UK.

LGV - Endemic in Africa, Latin America and Asia. With small numbers seen in North America and Australia.

Recently there has been a resurregence in the reported cases in Europe with 25% of cases in the UK being asymptomatic and 50% of cases in Germany being asymptomatic. 

Germany also found that of the positive CT results in MSM 17% of rectal infections were LGV positive and 15% of throat infections were positive for LGV. I found the throat infections very interesting.

Entric Infections - Shigella, Hepatitis A, Giardia.

Outbreaks in MSM population in the UK - found to be higher in MSM that participated in Sex parties, Chem sex (slamming) and HIV+Ve practising CLAI. Are we missing these infections. We routinely test for Hepatitis A in our MSM population and we have great programs for free vaccination of Hepatits A. But shigella is not routinely tested for and requires testing of stool samples. 

Why are some common STI's neglected over others? 

Gwenda Hughes from the Centre for Infectious Disease Surveillance and Control at Public Health UK spoke about the surveillance of neglected STI's this morning. 

On average every year, there are around 358 million new infections of four curable STI's, which one do you think is the highest number?

Syphilis, Chlamydia, Gonorrhoea, or Trichomoniasis?

6.6 Million Syphillis infections, 78 Million Gonorrhoea, 131 Million Chlamydia and at the highest; 143 million Trichomoniasis.

Caused by the parasite Trichomonas vaginalis, it is nine times more prevalent in women and with the associated risk factors of lower socio economic factors, lower levels of education and increased number of partners.

With poor specificity on wet smears, limited surveillance data, and knowledge gaps in racial ethnic disparity target groups, this is an STI that would benefit further research. 

In Sydney we do see limited infections, and this is more common in rural Australian settings, and higher amount in Aboriginal Torres Strait Islanders. 

Lymphogranuloma Venerum  (LGV) - is commonly tested in Australia with positive rectal CT infections, but one point I thought was interesting the presentation was in Germany that out of 154 MSM with positive CT infection not only had 17% had LGV rectally, but 15% had pharyngeal LGV.

Would this number be similar in Australia with the Sydney study (David Templeton) showing 3 out of 75 positive LGV with rectal CT. 

Could we do pharyngeal LGV testing with positive CT Pharyngeal PCR swabs?

HCV Infections in HIV negative MSM on PrEP

I attended the oral presentation sessions today on STI Surveillance with four different speakers on the topics of

  1. "A tale of two halves, low extended-spectrum cephlasporin and high azithromycin resistance in Neisseria Gonorrhoea in Europe,2015.
  2. Predictors of Persistent and Recurrent genital STI symptoms at sentinel surveillance cities in South Africa.
  3. High Prevalence of Hepatitis C Virus among HIV negative MSM in Amsterdam PrEP project.
  4. Origin and predictors of early repeat infections among HIV negative women with TV receiving a stat dose of 2g of Metronidazole. 

I will speak mostly about the HCV study in Amsterdam, but I just wanted to quickly mention number one. Each topic was around 15 minutes long, so limited time for questions or follow up.

1. Michelle Cole from GASP (Gonococcal Antimicrobial Surveillance Program) spoke about how they are testing resistance to gonorrhoea with Ceftriaxone, Cefixime and on every third year Gentamicin.
- Overall 2134 isolates were submitted from 24 countries and 1 x Ceftriaxone resistance was found.
- Five isolates had high Azithromycin resistance in 2014, and there was a high amount of resistance found in Heterosexual men and MSM compared with females.

Conclusions; high but stable resistance to Azithromycin and low overall resistance to Ceftriaxone and Cefixime. The speaker had raised discussion points around possible resistance; ?Mono Therapy, Azithromycin for NGU or the high use of Azithromycin in general?

-------------------------------

 

3. Roel Achterberg - Amsterdam, spoke about the study looking into HCV prevalence in HIV- men, specifically looking at the PrEP implementation program.

It was discussed that over the years, HCV emergence was noted in HIV+ MSM, not knowing why HIV- men were unaffected, questioning Biological, behavioural or network factors? The research question was asked; Is there HCV prevalence among MSM and Transgender persons starting PrEP, and do they cluster with HIV+ MSM?

Participants had a choice of daily or Event required PrEP (not available in Australia under trial). All were tested with HCV Antibody and HCV RnA.

  • 376 participants 
  • 18 Participants HCV+ (Ab and RNA)
  • 1 RNA+ but Anti HCV Neg, 14 RNA and Anti -HCV pos, 3 HCV RNA Neg anti HCV pos.
  • People with HCV reported more CLARS than others who were HCV negative.
  • Chemsex was a high component.

Conclusion from the speaker was that HCV prevalence was higher than previously found with HIV negative MSM.

As EPIC data in Australia is still being collected and reviewed by the Kirby Institute, it will be interesting to see how our data compares to Amsterdam.

I spoke to Roel after the presentation and asked about continual testing and study with PrEP and if they noticed behavioural changes or rates of infection throughout PrEP, but this data was still not available for them also.

 

During lunch I attended a Roche sponsored integrated symposium titled ´Syphilis, Chlamydia, Gonorrhoea-Oh My: Diagnostic Advances, Hurdles and Considerations.

I used this opportunity to get a refresher on syphilis considering the rates we are experiencing in North Queensland and to see whether trends/testing/management vary in other parts of the world. It was a very informative talk and definitely made me consider other presentations of syphilis i.e chancres in non-genital sites ( fingers, tonsils etc).

 

Dr Marco Cusini of the University of Milan, Italy presented ´Current Trends in Syphilis Testing´. The landscape of syphilis in 2017 is that it is well and truly still present and a major public health problem. Late syphilis is rare in Europe but early syphilis still very prominent. Thankfully it is still highly sensitive to penicillin G. In terms of clinical diagnosis, syphilis can be difficult as it is `the great imitator´. Sites of the primary lesion can be extra-genital (and unusual locations), the morphology of lesions can be challenging and there may be a number of primary lesions. Occular involvement also needs to be remembered! 

The diagnosis of syphilis can be achieved through direct methods if lesions are present. This is a quick and in-expensive method but only useful if used under expert eyes. NAATs have the highest sensitivity and specificity. Serology needs always to be performed to confirm the diagnosis and for ongoing disease follow-up. 

Point of care testing are useful in developing countries and there is one FDA approved test. POC testing for syphilis shows good specificity and sensitivity but Dr Cusini stated that they were not really a substitute for serological testing if laboratory facilities are available.

Lumbar punctures need to be considered in anyone demonstrating signs or symptoms of neurosyphilis or demonstrating occular involvement.

Adequate response after treatment was discusssed. Generally an adequate response after treatment for active syphilis is considered a 4 titre decrease at six months. It was good to hear that at our clinic we follow similar guidelines.

Dr Cusini referred to the 2014 European Guidelines for the Management of Syphilis (Janier. et al, 2014) for further information regarding diagnosis and management. It is easily found on the web should anyone wish to read it.

Definitely a good refresher on syphilis and an interesting lecture.

 

Point of care testing - is it the way of the future? Dr Tarim Sadiq (St. George's University of London) Spoke about new POC testing technologies currently used and some that are in the pipeline of development. 

Dean street Clinic in London are currently utilising the GenXpert POC tests where results are available in 90 minutes. However most clients do not want to wait in the clinic for 90 minutes. Available now and with more in the pipeline are a new generation of POC tests where results will be available in under 30 minutes. Meaning that clients can receive treatment at the initial consult if they have a positive test result. 

In the not to distant future POC tests that can test for CT. NG. MG and TV will be available. And resistance testing for NG and Macrolide resistance in MG will be available in the POC Tests also. 

So what are the barriers to implementation of POC tests. And is there a space for their use in Australia. 

Firstly the COST - In Australia in the sexual health clinic setting we have access to tertiary hospital laboratories. Do we need to outlay more money for POC tests to be available  in the clinic setting?

And what are the public perspectives in relation to POC testing - are they open to the idea of using POC tests or do they want conventional laboratory tests thinking they are more accurate?

The talk at the conference is that POC tests are the way of the future, How we integrate them into our practice is another question.

The exciting thing that I believe comes from POC testing is that resistance testing for STIs will be available quickly meaning the right medication can be used first go. 

Thoughts? 

 

This morning started with a great presentation of two Plenaries, starting with Vaginal Microbiome Research by Jeanne Marrazo - ISSTDR President and Professor/Director of Infectious Disease at University of Alabama - Birmingham. The Plenary followed was PrEP implementation, covered by my other colleague, Tamara. 

Jeanne spoke around the importance of healthy vaginal Microbiome and the increased risk of acquiring HIV/STI's. Some of these topics are already known, but it's good to re visit the importance of education to clients and to increase health literacy.

The benefits of having an optimal vaginal environment will see lower levels of HIV in women, protection from pathogens such as Bacterial Vaginosis (BV), Chlamydia, Gonorrhoea and TV as well as optimal birth outcomes such as a normal birth weight, timing of delivery and fewer pregnancy associated infections.

What is optimal vaginal environment? <4.7ph is optimal and anything above would be consistent with BV, in line with other symptoms (NB: STIPU Australia say >4.5ph).

Jeanne discussed that overall, women with BV have a 60% higher risk of acquiring HIV through vaginal sex, and men who's female partner is HIV+ are more likely to acquire HIV if those women have BV. On this note, Jeanne also mentioned that yes BV is quite common in Sub Saharan Africa, and can considered "normal" but it's not optimal.

In conclusion, further research is needed and more data around HIV/BV transmission risk to women. An important point was raised at the end around PrEP (TDF/FTC) implementation in women, especially around vaginal mucosa versus rectal being less effective in early administration and also studies are showing Tenofivir can have reduced coverage when Gardnerella Vaginalis is present.

The second plenary by Sinead Delany-Moretlwe (blogged by Tamara) spoke about Tenofivir effectiveness in women and it showed a lower tolerance for missed doses in the female genital tract in comparison to protection in rectal tissue acquired much sooner. 

With PrEP studies in Australia mostly recruiting MSM, it's interesting to look at female vaginal health in relation to PrEP, considering future prescribing options and the importance of education around HIV risk, STI reduction strategies.

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. 

Dr Sinead Delany-Moretlwe presented a plenary regaring the implications of implementation of PrEP.

In November 2015 the World Health Organization recommended that PrEP be offered to high risk individuals. This was based on key evidence of 12 randomized controlled trials of oral PrEP effectiveness. PrEP was found to be effective at reducing HIV across age, gender or mode of HIV acquisition. The caveat to this was the effectiveness of PrEP depended on the level of adherence.

The greatest impact and cost effectiveness of PrEP will be in populations where HIV incidence is >3 per 1000 person years.

As a result of the WHO recommendations truvada as PrEP has been approved in more than 17 countries and just recently has been approved in Belgium, Portugal, Brazil and now the UK. US data of retail pharmacies has shown a dramatic increase in the rates of PrEP prescribing. There has been a 738% increase in prescribing since PrEP was recommended. UNAIDS has estimated that >160,000 people globally are currently on PrEP. However the targets set for those on PrEP by 2020 is 3 million people.

So what does PrEP offer for the patient? Decreased anxiety, increased disclosure amongst partners, increased intimacy and trust and increased self efficacy.

However there are significant barriers to PrEP use and these involve stigma surrounding its use. Other perceived barriers include:

1.) Safety in terms of side effects and effects on bone/renal health

2.) Resistance

3.) Longer term follow-up

4.) Development of safer drugs

5.) Potential effects in pregnancy and breast-feeding

6.) Cost especially if public funding is involved

The key questions to implementation include- how do you create demand? How do you supply demand? How do you support effective use?

Certainly many of the challenges can be seen as opportunities to strengthen and revitalize sexual health services for those most in need.

 

Dr Kevin De Cock delivered an insightful keynote lecture which has set the tone for what should be a very valuable conference. 

He presented the lecture titled " HIV, STIs and evolution in global health". Global health involves a a complex interplay of many different facets and although gains have been made in some areas, there is still unfinished business to contend with. These include finding a cure for HIV, vaccine development for HIV, TB and malaria and shorter answer simpler treatments for TB. 

In terms of STIs there are changes and goals to be achieved. This was highlighted with the numbers of cases of syphilis, rising in the US since 2001.  Of these increased numbers the majority of those affected are men, particularly MSM. Rate of congenital syphilis have risen by 35% ( did I hear that right?!) since 2013. What are we doing to decrease this burden? How did this happen? Is screening for syphilis occurring where the burden is highest?

Clearly there is no easy solution to these issues however it was concluded the forging alliances, stronger networks, deeper epidemiology and stronger science are part of the answer.

A very thought provoking keynote lecture....

 

 

The new WHO STI Treatment Guidelines were released August 2016 after 3 years of a very complex process, this was the first update since 2003. The recommendations were mostly based on very low - low quality levels of evidence but resulted in 'Strong Recommendations' or 'Conditional Recommendations'. 

Target populations were based on the same as Australian target groups but I was surprised to see the adolescent group include 10 - 19 year olds compared to Australia's young people aged 15 - 24 year olds. 

N. Gonorrhoea 

Recommended treatment 

* 250mg ceftriaxone IMI + 1gm azithromycin oral stat

When asked why 250mg ceftriaxone IMI as opposed to 500mg ceftriaxone IMI as recommended in may developed countries including Australia, Prof Magnus Unemo explained that there were no adequate RCT to support the larger dose worked any better than the recommended. 

Also they advised a 'Strong Recommendation' for all neonate to receive prophylactic treatment for prevention of gonococcal and chlamydial ophthalmia neonatorum, a practice abandoned in Australia with no subsequent increase in occurrence of infection or childhood blindness.

C. Trachomatis

* Azithromycin or doxycycline remain the treatment of choice for CT

* Anogenital CT - treatment changed to 7/7 of doxycycline 100mg BD.                                                                       Australian STI Guidelines recommend 7/7 of doxycycline 100mg BD if asymptomatic and 21/7 if symptomatic

Prof. Nicola Low advocated that the doxycycline regime of 7/7 of treatment still cures CT as well as if not better than azithromycin even if the course is not completed in non compliant people. 

* There is no evidence that repeating or lengthening the course of treatment is any more effective. 

Syphilis

* Nothing has changed in Rx recommendations for syphilis

* There is very low quality evidence to support the recommended treatment

* Treatment is based on 70 years of successful treatment.

I enjoyed Dr Francis Ndowa's analogy that there were no RCT proving the use of parachutes when jumping out of a plane greatly improved survival over not using one, so proving benzathine penicillin successfully treated syphilis didnt require RCT. 

* There is a pending global shortage of benzathine penicillin so alternatives include

        * doxycycline, ceftriaxone and in special circumstances azithromycin 

Genital Herpes

The only change recommendation for treatment is to increase treatment of the first outbreak of genital herpes to 10 days as most first outbreaks are prolonged.