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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The final information station on this Italian inspired food for thought train was a digestive Espresso of Epidemiology “Understanding our evolving epidemic”. 

 

First up was HIV and Ageing – Rosan van Zoest (PhD student at the Amsterdam Institute for Global Health and Development) used cohort data from large studies to separate the Myths from Reality. The opener of the talk was a review of all the suggested AANCC’s (age-associated non-communicable comorbidities). The following speech-bubbles were presented for unpacking “HIV causes accelerated ageing”, “Ongoing inflammation is the cause of comorbidities”, “Comorbidities are due to antiretroviral toxicity”, “AANCC’s occur more often in PLHIV” and “HIV causes premature ageing”.  Data from the COBRA, POPPY and AGEHIV studies were used to respond to the statements and one of the key factors strengthening the evidence was the importance of recruitment of appropriate HIV-negative controls and reference was given to the COBRA study that used HIV- and age matched blood bank donors as a comparison.  After reviewing the evidence, Rosen concluded when reviewing evidence one should be careful not compare ‘apples and oranges’, control groups are vital, AANCC’s are more prevalent in PLHIV, comorbidity risk in PLHIV is likely multifactorial and when considering the above speech-bubbles the following should be considered; smoking, drug and alcohol use, CVD risk and DM, weight related conditions such as obesity and anorexia, HCV, systemic and intrathecal immune activation, certain ARVs and nadir CD4.

 

As Milan is one of the fashion capitals of the world it seemed appropriate at some point that we talk about Modelling… kind of… Supporting the development of evidence based police/management guidelines was presented by Mikaela Smitt from Imperial College London.  This session was focussed on the “black box” of modelling studies and for those that can comprehend this analogy she used a picture of big yellow minion and thought bubble “WHAAA?!?!?!” as the opening slide…a sentiment I am familiar when trying to get my head around modelling.  Needless to say, she unravelled it brilliantly.

What is modelling and what does it do? It predicts the future, compares interventions, uses epidemiological mechanisms, uses fundamental parameters and suggests resource allocation.

What is good model practice? A new acronym was given to use here (and a picture of the popular Harry Potter Hogwarts popular sport) QUEDDACH.   The QUESTION is concise and specific including outcomes, measures, settings and timelines.  The DESIGN includes what key elements and interactions are represented.  The DATA is underpinned by key/strong data sources.  The ASSUMPTIONS should be defined as well as what impact they have on the results. The CHECKS and sensitivity/uncertainty analyses should be done.

And finally what are the potential problems with modelling data? Wrong tool is used for the job, garbage in = garbage out, Complex questions = greater uncertainty

 

 

And so for my final blog of Mind stimulating Mozzarella… (Sorry am running out of cheesy puns.. whoops and again!)

 

“What is happening with new HIV diagnoses in gay men in England and why? Interpreting monitoring (outputs) and surveillance (outcomes) information” presented by Professor Noel Gill from Public Health England.  Noel started by commenting on England as a high-income setting, the open access network of 200 STI clinics held in high regard by at risk community and excellent surveillance and monitoring systems.  He posed the temporal changes from 2010 onwards noting the HIV complacency with increasing survival and better ARV regimens, problematic increasing density of sexual networking driven by the arrival of geospatial hook-up smartphone apps and a marked increase in bacterial STI’s.  Trends in common STI diagnoses were examined as well as reviewing some of the policy developments affecting them such as behavioural interventions, lower thresholds of access to HIV testing (e.g. the Dean St 1hr promise, self-sampling and Self-testing), Increases in HIV testing frequency following recommendations of 3 monthly testing for those having condomless AI with new or casual partners and HIV PrEP (PROUD trial commencing in 2013). 

 

Noel concluded with the following information on Preventing HIV in MSM.  Combination prevention has seen a 50% increase in MSM clinic attendees from 2011 – 2016, intensified testing of those at risk has seen an average of 2.5 test annually in 2016 and suggested the question clinicians should be asking is “How frequently are you testing, not when did you last test”.  Shortening the time to treatment initiation in PLWHIV and HIV PrEP has all had a significant contribution. Noel closed by highlighting the commencement of the IMPACT study a pragmatic health technology assessment of PrEP and its implementation that aims to answer the key questions under real world conditions and at sufficient scale.  The results will inform service commissioners on how to support clinical and cost-effective PrEP access in the future.

 

 

 

Thank you to ASHM for your generous scholarship funding for myself and the other Australian sexual health clinicians who benefited from this – we had a blast!  Ciao x

Day 3 at #EACS2017 and my neurone nourishment started with an Antipasto of "Abstract Writing" by Caroline Sabin (Professor of Medical Statistics and Epidemiology at University College London (UCL)). This was an early morning session and the smaller audience lent itself well to an interactive tutorial style where we were asked to critique a ‘poorly written abstract’.  Here are the bite-sized “do’s and don’ts”.

 

TITLE – Should be short and snappy. DO NOT inaccurately represent the project.  Questions are often great to pose in a title.

INTRO – V. brief!  One sentence to describe the problem and one to describe the research. Hook the reader here by this point the reader should know what you are going to do.

METHOD – Population, location & dates. Identify assessments and methods, endpoints and outcomes.  Describe the stats method (no need to mention the stats model used), DO mention confounders. DO NOT put results here and no need to mention detail such as assay types etc.

RESULTS – DO mention brief demographics of sample, this section should be numbers rich, confidence intervals and comparative statistics.  DO NOT discuss interpretations here. 

CONCLUSIONS – DO NOT repeat results (keep it brief).  DO aim for one or two statements – How will this help?  What is the future? Any major limitations?

 

Having reviewed many of the abstracts for EACS Caroline’s feeling is that the abstracts tell the reviewer as much about you as it does about your research.  With this in mind her final tips included ensuring correct English language and grammar, is this the right conference for you?, no need for references, use ‘dashes’ effectively they will help your word count, be careful with bold and italics it does not always translate, a little tip …if you must use a table JPEG images often only use one character, avoid jargon.  Finally she commented that abstracts that did not get accepted are largely due to lack of clarity on the project, inappropriate for the conference, poor study design, no sample size mentioned, no bias acknowledged, no clinical value. 

 

 

 

Next up for something to chew on was the first plenary Eradication of Hepatitis C in HIV coinfection presented by Andri Rauch (Associate professor of infectious diseases, University Hospital Bern, Switzerland).  Andri reminded us of the WHO goals of Hepatitis C management.  He discussed the higher the HCV prevalence, the more treatment is needed to achieve elimination.  Scaling up harm reduction reduces the required treatment rates.  He demonstrated a colourful “spaghetti junction” of graphical information showing clusters of behaviours and phylogenetic analysis of international transmission networks to show areas where trends of information can be used to improve counselling and behavioural interventions and where targets for disruption of transmission needs to occur to aim for elimination.  Focusing on Europe he showed data which demonstrated the hurdles to HCV elimination in Europe which are largely around access to therapy, affordability and reimbursement restrictions.  The proportion of re-infections increases with treatment upscale but overall incidence and prevalence decrease if risk behaviour stabilises.  Fear of re-infections is NOT an argument against treatment upscale. In conclusion he stated the central elements of HCV elimination include 1) Optimized screening and diagnosis strategies, 2) Optimized prevention and risk counselling, 3) Increased treatment uptake and access to IFN-free DAA for all at affordable prices, 4) Coordinated national and international HCV strategies and leadership. 

Just after lunch I attended a session chaired by Gus Cairns, an HIV activist from the UK who spoke passionately about the need for PrEP in Eastern Europe earlier in the conference. A few speakers provided their thoughts on what might be holding things up with PrEP:

 

Justyna Rowalska from Poland presented HIV practitioners perspectives on PrEP in East, Central and South-Eastern Europe, the findings of a survey of many clinicians about PrEP. The findings concluded that the main obstacle to prescribing is not being covered or paid by public health, and that there was no official medical approval for the medication in many countries yet. She stated most said they would prescribe it if it was approved, but that clinicians needed guidelines in their countries, wanted a government strategy that includes PrEP and off label approval.

Gennady Roshchupkin from Georgia then presented Georgia’s PrEP demonstration project that has recently commenced with 100 places in 2017 and a further 100 in 2018, funded by the Global Fund but proposed his concern about what will happen when/if the Global Fund revokes funding. He suggested that the logical solution would be to involve some local NGO’s but that they were used to deal with people in crisis, and PrEP isn’t really a crisis. He thinks co-payment schemes and de-medicalising the delivery of PrEP may also keep costs down.

The panel then commenced discussions. Italy’s comments are of note: Italy has no reimbursement for PrEP and most are sourcing over the internet. The panellist (I have not recorded his name, apologies) stated that the discussion should no longer be medical or scientific, it works, and medical staff need to start advocating for MSM and working with MSM if they are ever going to reach the 90 90 90 targets by 2020.

I saw many other presentations today which will be blogged about by my fellow ASHM scholarship recipients, all of which have been equally as thought provoking and my brain is ticking over with ideas to bring home to Clinic 275. Witnessing the European perspective has been really enlightening.

 

I’m very grateful to ASHM for the opportunity to attend this wonderful international event and strongly encourage other nurses to apply for scholarships in the future– sure, a bit of the science that was over my head but there was still plenty of research that I could sink my teeth into and learn a lot from. Buona sera from Milan, Emma

A topical presentation by Adam Bourne from London UK on the last day of EACS conference.
 
Different countries tend to have their own favourite chems .The main drugs being used are GHB/GBL, crystal, ketamine, and mephedrone. Drug taking with sex isn’t a new practice but the facilitation through social apps such as Grindr is, as well as increased use in group sex settings .
 
A recent UK study showed 6.6% of MSM had used one of the above drugs in the previous 4 weeks during or before sex. So although topical in the media, Chemsex use is a minority behaviour at a population level at the moment. Chemsex was commoner in HIV positive individuals with almost 21.9% having used in the last 4 weeks. The reasons for using chems during sex were varied and included sexual disinhibition, enhanced sexual pleasure, overcoming negativity/low esteem associated with HIV diagnosis and dealing with impaired libido.
 
Chemsex is associated with a higher risk of HIV/STI transmission behaviors. The strongest association was between crystal meth and unprotected anal intercourse and binge alcohol use.
The presenter didn’t have time to discuss other physical/mental or social problems of Chemsex, only mentioning risks of dependence for sexual performance and also OD risks especially with GHB.
 
Social apps such as Grindr have been targeted as an important means for sexual health harm minimization in Chemsex users.

Adam Bourne (La Trobe University, Melbourne) defined “chem sex” as recreational drugs, (usually crystal meth, methedrone, GHB , GBL, or ketamine) taken immediately before and/or during sex between men. It is facilitated by sexual networking apps and SOP venues. In his study of MSM: 6.6% had used in the previous 4/52 but 21.95 of HIV+ve  men. The figure rose to 32.7% in London.

The figures varied from 5-15% in a European MSM internet survey. Participating in chem sex was strongly associated with previous drug use, STI, PEP use and group sex. It came with an increased risk of UAI and new partners. It may be used to overcome a reduced libido but once indulged can lead to difficulty in enjoying “sober”sex.

 

Dominic Rowley (consultant in sexual health and HIV medicine at The GUIDE Clinic at St James’s Hospital in Dublin) talked about emerging STI’s and resistance:

50% of HIV diagnosis in 2014 were late presenters and synergy with STI’s is well known. For example the presence of urethritis is associated with an 8 fold increase in vRNA. He reviewed the state of play of STI’s:

 

NG 80,000 in Europe 2015. MSM majority and increasing. Ceftriaxone resistance emerged in Japan in 2012 and is a great concern.

CT 350000, and commoner in heterosexual population. There is a 10% failure oral infection clearance with azithromycin when compared to 2% with doxycycline. It has been suggested that a single dose of  azithromycin may not be enough. He recommended a test for cure in all patients or to use doxycycline 100mg BD for 1/52. He highlighted the anomaly of not performing anal/throat swabs in heterosexual females despite the knowledge that UAI/oral sex is common.

MG he referred to the Melbourne study recommending an initial 1/52 doxycycline course followed by azith or moxifloxacin.

Syph increasing incidence and increasing macrolide resistance

Shigella  emerging as an STI associated with oro/anal contact like HepA

LGV increasing incidence in Europe

 

Luisa Salazar-Vizcaya (Postdoctoral researcher; Inselspital, Bern University Hospital, University of Bern ) looked at nsCAI (condomless AI with non steady partner) in MSM. she found a general increase over the past 10yrs. She described 4 behavioural clusters and postulated that awareness of reduced HIV transmission with ART, and awareness/availability of PrEP had led to this finding.

 

David Zucman (Internal Medicine, Hopital Foch, Suresnes, France) reported a recent Hepatitis A outbreak in MSM , the largest in history and an emerging worldwide problem. There is now a worldwide shortage of HepA vaccine as well as HepB which I was unaware of; I suggest ordering supplies immediately! He found that although 76% of HIV +ve were immune only 39% of HIV-ve were.

 

David Stuart (ChemSex support programmes at 56 Dean Street sexual health clinic in London) and David Atefi (Atlanta Gastroenterology Associates) described the provision of chem-sex support at the Dean St Clinic in London. This has been running since 2011 as a walk-in clinic. They see 40-50 clients/week. His study showed significantly higher rates of STI/HIV testing rates and self-reported improvement in  confidence in managing their chem use and risk taking behaviour.

 

Teymur Noori (European Centre for Disease Prevention and Control Solna, Sweden) reported from the Hornet/ECDC study showing attitudes to take up of PrEP. 17 questions were presented in 8 languages via the Hornet MSM app. They had 12,053 responders of which 11%HIV+ve. 10% were using PrEP of which 50% was from a doctor but 50% was informal supply. 31% had not informed their health provider. 

Of those taking PrEP, 50% had also taken PEP, were more likely to be  tested for, and diagnosed with STI’s. They also reported greater happiness with their sex life!

 

Valentina Cambiano (Research Associate in the Department of Infection & Population Health at the Institute of Epidemiology & Health Care at University College London) presented some results from the aurah2 study. This study was conducted in three sexual health clinics in U.K. Between 2013-2017. 668 completed annual questionnaires. She found increased PrEP awareness from 43-92% in the period and 23% rate of use. she made the point  that these clinics had  taken part in the PROUD study and that awareness may have been higher. I was also surprised at the 85%+ caucasian / 75% tertiary educated demographic which I thought underrepresented the lower SE classes in London particularly.

 

Overall this was a very interesting session although, as one of the chairs mentioned: no one had addressed the definition of “bad sex!”

This morning I attended a series of presentations under the heading ‘Understanding our Evolving Epidemic’ and witnessed some of the most interesting sessions I’d seen so far, some even getting a bit heated!  A few topics were about mathematical modelling and these poor statisticians are clearly used to having people leave their talks as they were very apologetic before presenting. What does it say about me that I really found them very interesting?! I’ll attempt to summarise the key messages below:

 

Mikaela Smit (Research Associate at the Department of Infectious Disease Epidemiology, Imperial College, London) discussed how mathematical modelling can support the development of evidence based policy and guidelines in relation to HIV. One model they had developed to forecast non-communicable disease burden in HIV positive patients from the Netherlands concluded that in the future most medical issues would be cardiovascular, and that 40% of these patients would have issues with medications.

In another modelling study Katharina Kusejko (ETH, Zurich, Switzerland) looked at HIV epidemiology in Switzerland and concluded that PrEP had a higher influence on HIV acquisition that condoms and ART; the modelling demonstrated that providing PrEP for 50% of MSM would prevent 250 new cases of HIV. There is currently no PrEP in Switzerland, so this study may assist the case for it.

One further modelling study was presented by a very lively David van de Nijver from the Netherlands on the Cost effectiveness of PrEP in Germany. In Germany a generic brand of PrEP has become available at the cost of €834/year compared to branded PrEP at €9512/year. His study showed that the cheaper brand could save 4 billion Euros and that Germany would break even after 10 years while most importantly averting 10,000 cases of HIV after 12 years. He insisted that Germany needs to invest now to get the savings and gain money for the future. 

 

It seems sitting through modelling studies is worth it in the end as I learned a lot! Such powerful findings that can influence public health policy. 

As my patients are almost all women living with HIV and from an African background who are very keen to breastfeed, this session was number one on my priorities to attend despite being yet an another 7:30am presentation. 

 

The presentation was set up as a debate with three speakers although in the end, they all came to a similar conclusion!

 

First was Dr Karoline Aebi-Popp (Obstetrician & Gynecologist (German Certification), MSc Infectious Diseases – Specialized in Sexually Transmitted Diseases, University Hospital Bern,Switzerland) who presented the ‘no’ side to the question of whether all women is Europe living with HIV should breastfeed. 

 

Worldwide, 150,000 child acquired HIV in 2015 and 1/3 of these acquired their infection from breastfeeding. Karoline did point out that most of this data is African data. Although ART reduces the HIV RNA levels in breastmilk it does not reduce the HIV DNA levels. There is also evidence that some of the ARTs get into the breastmilk such as dolutegravir which has a number of potential problems. 

There is a risk of resistance if the infant is exposed to monotherapy via breastmilk. Also there is a risk of delayed diagnosis if the baby is positive but ART suppresses virus replication.

Overall from meta-analysis of all evidence of breast feeding in HIV, the risk of MTCT ranges from 0.9%-4%.  Is this acceptable given in high income countries we have access to a safe alternative which has a 0% risk of MTCT?

 

 

Dr Fiona Lyons (consultant in Genitourinary and HIV Medicine at the GUIDE clinic, St. James’s Hospital, Dublin, Ireland)spoke next on the ‘yes’ side supporting breastfeeding in maternal HIV. 

Fiona made the important point that we need to not just look at MTCT but also benefits of breastfeeding for the mother including breast cancer reduction. She produced evidence that MTCT in an ideal world is less than 1%. All the evidence we have about breastfeeding in maternal HIV Infection includes low and middle income countries which may not reflect the potential in high income countries with safe access to bottle feeding and high quality HIV care and follow up. 

She emphasised a patient-centred approach with an individual assessment of each patient and their circumstances. 

 

 

Dr Karina Butler O’Connell (UCD Clinical Professor of Paediatrics, Consultant Paediatrician and Infectious Diseases Specialist at Our Lady's Children's Hospital and The Children's University Hospital, Temple Street, Dublin, Ireland) spoke on behalf of the child. She presented the evidence that in low and middle income countries breastfeeding actually decreases mortality due to reduction in diarrheal diseases. However even in high income countries, the MTCT rate was not zero. This risk goes up when we look at actual behaviour not just ideal behaviour (reduced adherence to medication, lost to follow up etc). For the child, she felt this was not an acceptable risk. 

 

 

I look forward to the prospective cohort study that Karoline is involved in looking at transmission rates in breastfeeding. 

 

In summary

  • have an individualised approach
  • Better to allow the mother to discuss in an open environment. 
  • We need more research particularly around models for supporting breastfeeding

Below is a link to Lancet review and discussion of evidence in HIV and breastfeeding. 

 

http://www.evidentlycochrane.net/lancet-breastfeeding-series/

 

I found this session particularly good and relevant to my practice. I also ran into my mentor for HIV prescribing Dr Olga Vujovic from The Alfred hospital in Melbourne at this session which was great!

 

 

 

 

 

Posters; PrEPX findings, and mobile apps

b2ap3_thumbnail_EACS2017_Poster3.jpgb2ap3_thumbnail_EACS2017_Poster4.jpg

BBetween sessions I had an opportunity to view some posters highlighting excellent research from around the world. I was happy to see some findings from PrEPX in Victoria:

 

Sexually transmissible infections as HIV risk markers at baseline in PrEPX, a large Australian PrEP trial – An analysis of formal eligibility criteria; Dr Vincent Cornelisse (Prahan Market Clinic, Melbourne) concluded that participants who were enrolled despite not meeting eligibility criteria still had substantial prevalence of STI’s (7.1%) which suggests that someone requesting PrEP is likely to be at considerable risk of HIV, even if they do not meet the eligibility criteria.

Comparison between HIV risk reported by clinicians and HIV risk reported by participants at enrolment in PrEPX, a large Australian HIV pre-exposure prophylaxis study; a finding of this analysis showed that patients may over-report CLAI with HIV + receptive sexual partners to their PrEP providing clinicians, but under-report methamphetamine use and CLAI with casual partners.

There were 2 interesting posters on smartphone app use to reach target populations. This research builds on what we learned earlier in the day’s plenary sessions about utilising low cost technologies where possible in resource poor environments:

Understanding the Impact of Smartphone Applications on Sexually Transmitted Infections (STI) and HIV prevention among Men who Have Sex with Men (MSM) in the EU/EEA, highlighted that smartphone apps are currently under-utilised and that realising their potential requires support, engagement, and coordination from EU stakeholders and engagement with the private sector.

Harnessing the Power of Smartphone Dating Apps and Online Tools to Increase MSM testing in Europe and Central Asia through a Community, Business and Public Health Partnership, described a partnership between 3 smartphone apps (Hornet, Grindr and PlanetRomeo), the ECDC and European HIV/Hepatitis Testing Week where the apps provided free advertising to promote a site with information about testing sites across Europe and Central Asia (European Test Finder). The app pushed out information to millions of users in 40 local languages in 53 countries resulting in 65,614 hits. This demonstrates the power of partnerships between public health and private sector business in improving access to education about testing for HIV.

 

Tagged in: EACS 2017

Next up for me today was the Epidemiological challenges of HIV surveillance presented by Anastasia Pharris.European Centre for Disease Prevention and Control (ECDC) in Stockholm, Sweden  Anastasia showed data highlighting the contrast in reported routes of HIV transmission by European sub-regions in 2015 across the West, Centre and East.  Heterosexual transmission accounting for a significant portion across all areas, injecting drug use significantly more in the East and MSM transmission more in the west and centre.  She demonstrated that sex between men is significantly underreported and stigma and discrimination is still a huge barrier. Anastasia commented that Europe is lagging behind in its response to the HIV epidemic and it is not on track to reach the 2020 targets.  She highlighted there are some issues urgently still needing to be tackled, one in particular is the development of policy to include undocumented migrants which account for a proportion of the late presentations and also community viral load which has public health implication.  Finally she talked about more wide scale role out of some successful models such as community based testing, home sampling, PrEP scale up, harm reduction efforts such as needle syringe programmes and opiate substitution programmes and reduction of stigma.

 

Following on from the breakfast buffet of the bright future for ART and European epidemiology I moved on to the Industry sponsored degustation menu of case studies entitled “Seeing the whole picture” presented by Giovanni Di Perri, Professor of Infectious Diseases at the University of Turin, Italy  & Jürgen Rockstroh, Professor of Medicine and Head of the HIV Outpatient Clinic at the University of Bonn in Germany and a panel of experts. 

 

Giovanni Di Perri opened the session discussing the prevention of harm in patients with HIV and detailed the common comorbidities associated with HIV and the impact of long term ART such as neurological impairments, cancer, CVD, Bone disease, liver and kidney disease. He highlights the need to carefully manage our patients as a whole, going beyond undetectable, to improve their overall health by considering comorbidities (prevent and treat), counselling our patients on lifestyle risk factors and careful selection of ARTs that balance HIV efficacy, durability and toxicity.  3 case studies were then presented by panel members focusing on differing disease burdens such as bone density, renal function, and prevention in the healthy client with lifestyle factors such as smoking.  Audience participation was required for responses on care priorities, comorbidity treatment options, ART switches and perhaps the one with the most diverse spread of results was in answer to the question when to start ART treatment in the case of a 23yr old MSM diagnosed with HIV that day.  40.4% of the audience said ‘immediately (today)’, 43.8% said ‘once all baseline data were available’, 1.1% answered ‘CD4<500’, 1.7% said ‘Wait, this patient is too young to start lifelong therapy’, and 12.9% said ‘Wait – I need to assess whether this patient will be adherent’.  In this panel discussion reference was made to the San Francisco experience of same-day observed ART initiation versus standard of care and its benefits to viral suppression.  Overall feeling from the panel was a slightly more cautious approach to treatment initiation where one awaits resistance profiling and other baseline assessments before commencing ART to allow for adequate characterisation of any co-morbidities and also time to spend with the client getting to understand their wishes, likely adherence and willingness to start therapy.

 

And so concludes the second day of yet more mouthwatering (or rather thought provoking) messages and i look forward once again to more palate pleasers tomorrow! 

 

 

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So having digested all the scrumptious brain teasing morsels at yesterday’s info picnic what was on the menu for Day 2 at #EACS2017?

 

To begin the day Dr Roy Gulick, Professor of Medicine and Chief of the Division of Infectious Diseases at Weill Medical College of Cornell University (also see Mark Ryan’s post) presented the Future of HIV Therapy.  He began by summarising approved ART first line regimens in 2017 and the world-wide opinion to start at all CD4 counts whenever the patient is ready.  He discussed the developments of ART properties in terms of

1)           Antiretroviral activity - mentioning the future of two new classes of drugs HIV Maturation Inhibitors and HIV Capsid Inhibitors,

2)           Safety and tolerability- giving TDF -> TAF switch as an example of similar viralogical efficacy but improvements in renal and bone markers. 

3)           Convenience- recapping the history of ART with many daily pills to the current single tablet regimes and then the possibilities in the future of new co-formulations with longer half-lives lending themselves of less frequent dosing, and long acting methods in the form of injectables and subdermal implants.

4)           Access and Cost – Highlighting the numbers of people living with HIV globally and improvements in those accessing treatment as the cost of ARV’s decreases.

5)           Life expectancy as those with HIV live longer and healthier lives and in closing stated “possibly longer than the general population … apparently getting healthier is good for you”

 

 

Dr Anastasia Pharris from ECDC in Stockholm gave a detailed and insightful presentation on the state of HIV in Europe.

 

Current situation 

  • Globally HIV incidence is decreasing due to ART and viral suppression, but Europe is still increasing, mainly in the east
  • 80% of new HIV infections in Europe in 2015 were in Eastern Europe and mostly attributable to IDU but this is declining over time
  • MSM may be under-reported in the East
  • Mother to child transmission is very low in virtually all countries

Is Europe's response to HIV sufficient?

  • Probably not as many people are diagnosed too late
  • There is a big move now to test and treat regardless of CD4 but in undocumented migrants this falls short
  • Viral suppression is achieved in many countries, but Russia and the East are well below targets

Challenges and opportunities moving forwards

  • Europe needs to implement what they already know works
  • Harm reduction coverage remains low in parts of Europe and should be improved
  • Changing the culture of testing to community based, home sampling and non-medical staff will expand in the next 10 years
  • Many countries are still on the fence about PrEP, particularly in the East
  • 2/3 countries in Europe report that funds for HIV prevention are insufficient to implement the necessary prevention strategies
  • Low cost interventions should be utilised to target populations at risk e.g. Health promotion through apps (I will discuss an interesting poster about this in a later post)

Stigma remains an issue and Europe is not addressing this adequately

This was a very interesting discussion and there are points to consider in the Australian context – the use of mobile technologies and partnering with the private sector in this space; maximising access to harm reduction strategies as we know this works; and looking at expanded opportunities for testing outside the medical model to engage high risk populations.

 

 

 

 

 

Tagged in: EACS 2017

Robert Zangerle (Austrian Society of Dermatology and Venereology) found thatanal cancer is 300x more common in HIV+ MSM in Austria. He studied the extensive database of the HIV cohort  2003-2015 where he identified invasive anal Ca in 47/7500 patients; of these, 7 died of their cancer and 4 of AIDS related illness. There was no information available on sexual habits and HPV vaccination rates (assumed to be very low.)

 

Carmen Hidalgo-Tenorio (Infectious Disease Unit, University Hospital Virgen de las Nieves, Granada, Spain) looked at HSIL in HIV +ve women in Spain. Of the 95 women,  28.4% had had anal intercourse. Anal cytology was normal in 46%, 22.1% were positive for HPV with a negative smear, and 13% were  atypical. She found HSIL IN 16/100,000. Significant predictors for HSIL were number of sexual partners >3 and abnormal cytology. Interestingly atypical anal cytology was commoner than cervical in HIV positive women.

 

Alessandra Vergori (Rome, Italy) reminded us that PLWH have 15-25 x rate for  anal ca and 2.1 x that for oral. She studied 395 HIV +ve men. 96% were on ART, 47% were smokers. The average number of sexual partners were 100 for MSM and 12% in heterosexual men. HPV was present in 20% oral, 83% anal testing and 50% of anoscopy samples showed atypia. Significant associations were the number of sexual partners and a low CD4 count.

 

Deborah Konopnicki (Centre Hospitalier Universitaire Saint-Pierre, Brussels) gavethe stark statistic that the mortality rate for invasive anal Ca is 31%. Screening for anal and oral HPV is difficult and a more practical approach is vaccination. HPV vaccines are virus-like particles and completely non- infectious. 9vHPV is now available covering serotypes 16/18/31/33/45/52/58/6/11. Good AB levels persist for at least 12 yrs following vaccination. Vaccination has been proved to be safe and effective in HIV+ Patients but vaccination is much more effective in everyone when given before significant HPV exposure ie. in early teens. EACS recommendations are to vaccinate all women up to age 26y and all MSM to 40y if HIV +ve or 26 if -ve

Vaccination reduces relapses in treated HPV by 65% in women and 50% in men.

It has been shown that if vaccinated under 15yrs, 2 doses and probably 1 dose are as effective as the triple dose regime. The consensus appears to be that single dose vaccination will be recommended in primary vaccination of teens but 3 doses are still required in HIV patients.

 

 

Laura Benjamin (Wellcome Trust Liverpool Glasgow Centre for Global Health Research) presented her research on a cohort of HIV patients suffering stroke in Malawi. She found an increased risk associated with lower CD4 count but not with viral load. The strokes were mainly ischaemic rather than haemorrhagic. There is increasing evidence of stroke as a co-morbidity and it is thought to be due to HIV- related vasculopathy causing inflammation and endothelial dysfunction. It is important to consider treatment failure with opportunistic infection if stroke occurs in someone on ART. 

 

Neurocognitive impairment remains an important problem in HIV patients despite ART. Carmela Pinnetti (Italian Ministry of Health) presented a study exploring the  association between neuronal injury markers and NCI. She confirmed that plasma and CSF markers were important indicators of impending NCI. Valentina De Zan (Department of Microbiology, Verona University) then pointed out that despite ART, the HIV  virus may persist in CSF and can escape causing neurological symptoms. She studied 46 neuro-symptomatic. She found CSF viral detection at a higher rate than plasma as well as undiscovered viral resistance. Optimisation of ART led to 65% recovery although a few relapsed at a later date.

 

Aoife Cotter (Consultant in Infectious Diseases at the Mater Misericordiae and St Vincent’s University Hospitals)presented the POPPY study. This looked at an aging group of HIV patients, over and under 50yrs against controls over 50yrs. The older patients had lower BMD after correcting  for other variables. A higher CD4 count and current  ART were associated with lower BMD. Tara McGinty (Clinical Research Fellow, UCD School of Medicine, Dublin) confirmed HIV as an independent predictor of reduced BMD but stressed the need to assess trabecular bone score as well, (this is also reduced in HIV.) The lumbar spine is more effected and predictably smoking, and prior fracture were the most important predictors of more severe osteoporosis 

 

Pablo Ryan (Hospital Universitario infant Leonor, Madrid) pointed out that osteonecrosis is more common in people living with HIV (PLWH.) They require THR. He compared complication rates in HIV vs controls in 348,000 patients who underwent THR in Spain including 1018 HIV+ve. ON rates were higher in HIV but there were no differences in surgical complication rates.

 

 

Prof Nicola Gardini teaches Italian at Oxford University and is a researcher of renaissance texts, a translator, author and poet. He gave an erudite and thoughtful paper on "illness" in literature, his interest in this started when he translated Virginia Woolf's essay "on Being Ill " and developed further when exploring the writings of AIDS Sufferers. In his opinion whether we are living or dying is a linguistic construct. He pointed out that as doctors we are engaged in narratives as we diagnose and that in this we are similar to an author developing the plot of a novel.

He describes AIDS literature as initially being all about dying and loss, but now about infection and disease. He used the seminal work by Edward White "A Farewell Symphony" 1997 as an example. In his opinion literature can be an antidote to bias and stigma. It gives a voice and expression to gay men and AIDS sufferers. He made an interesting observation that literature is kind to TB compared AIDS with its attendant decline in body and lack of "spiritual lifting up."

His recent novel: "La vita non vissuta" (The Unlived Life) describes the story of a man leaving his wife for a male lover, only to be infected by him with HIV. It describes his coming to terms with his infection and "being ill" he ended his lecture with the point that it is possible to be "I'll" but still healthy in mind and body.

 

 

Plenary Lecture: BIG (data/mistakes/Brother)

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

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

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

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

 

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

Diagnosis and management of Non-Alcoholic Steatohepatitis (NASH) & Non-Alcoholic Fatty Liver Disease (NAFLD)

 

Sanjay Bhagany (Consultant physician/honorary senior lecturer in infectious diseases/HIV medicine, Royal Free Hospital, London)

Emmanuel Tsochatzis (senior clinical lecturer and consultant hepatologist at the UCL Institute for Liver and Digestive Health, Royal Free Hospital, London)

 

 

Abnormal liver function (LFT) tests and fatty liver are common and often frustrating conditions seen in general practice. I see a significant number of refugees who have abnormal LFTs as well as managing patients with HIV with abnormal LFTs so I was keen to get up early and get to this 7:30am lecture!

 

Emmanuel made the important point that you can’t always trust the LFTs. Patients can have severe disease with normal LFTs and grossly abnormal LFTs with just fatty liver.  It is important to remember that 25% of general population have fatty liver and of those 10% develop cirrhosis. 

Fibroscan is important for assessing liver disease although for rural towns like mine, access can be an issue. 

 

Steatosis can cause over-estimation of stiffness in fibroscan.  A fibroscan result of >7 is worrying in fatty liver.

 

Important strategies for everyone with abnormal LFTs associated with fatty liver include addressing CVD risk factors, there is some evidence this will improve fatty liver.  We should be considering fatty liver as part of metabolic syndrome, commonly managed in general practice.  Extending this to people living with HIV is important as HIV infection itself is fibrogenic.

 

NASH/NAFLD prevalence in people living HIV is up to 50%. Causes are multifactorial and include HAART therapy plus virus protein inflammation plus lifestyle. Nadir CD4 count and a history of use of older HIV drugs are risk factors for liver disease.

Emmanuel talked about some of the difficulties in making an accurate diagnosis of fatty liver including ultrasound and biological markers as well as non-invasive assessments, all of which have their limitations. 

Treatment essentially is about reducing weight including bariatric surgery if appropriate.  Emmanuel talked about the experimental use of maroviroc.

 

 

In summary, it is important to think of NASH/NAFLD in people living with HIV and reducing cardiovascular risk and monitoring of progression are the mainstay of management. 

The Round table meeting made some interesting points concerning the recent instigation of PrEP in the UK and France.

 

 Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot, France) showed that daily and on demand PrEP is cost effective for the community. More importantly it has helped take the fear of sexual activity and anxiety from a population that are over represented  when it comes to mental health care issues. He felt that PrEP is still not reaching high risk groups such as  young MSM, migrants and the trans population. Young MSM are a particular problem  in that they often feel stigmatized about their sexuality and unwilling to  engage with the medical profession. They may also be in some denial about their HIV risks and are a difficult population to ensure compliance with medication. Social media apps eg Grindr, Hornet and Planet Romeo are very important  resources for HIV ,PrEP and PEP education.

 

PROUD and IPERGAY studies have confirmed the effectiveness of daily and intermittent/ on demand Truvada.(4 tabs). Maraviroc was not shown to be an effective PrEP agent. Current studies with TAF/FTC are promising as is injectable Cabotegravir LA. Topical drugs such as vaginal gels also have an important place. The possibility of future over the counter PrEP raised some concern by the panel who felt  medical intervention is needed at some point in the PrEP pathway.

 

Emma Devitt from the Dean Street Clinic Soho, UK showed some impressive rates of decline in new HIV diagnoses in the last year. She felt this was due to a combination of factors their clinic offers including:

-frequent screening for HIV 

-rapid ART instigation for HIV positive people

-regular STI screening and rapid Rx of STI

-use of PEP and now PrEP

 

A very informative and topical meeting  from some incredibly dedicated and progressive doctors.

 

also see blogs from Rebecca Houghton and Emma Clements on this topic

Tagged in: EACS 2017 PrEP access

The Future of HIV Therapy

Dr Roy Gulick (Professor of Medicine and Chief of the Division of Infectious Diseases at Weill Medical College of Cornell University) from New York provided a great summary of current treatment guidelines and new developments underway with ART.

In summary:

ART is now recommended to commence at any CD4 count when a patient is also ready to start. If resources are a priority then treatment should be offered first to those with a CD4 <350.

There are currently 29 approved HIV medications and up to 10 starting regimes.

5 broad mechanistic classes (NRTI, NNRTI, PI, INSTI,EI)

Recommended standard strategy is 2NRTI +(NNRTI,PI,or INSTI)

 

If there is multiclass failure to the 29 drugs two new entry inhibitor class drugs are showing promise.

1 Fostemsavir (oral HIV attachment inhibitor with Phase 2 results soon to be released)

2 Ibalizumab (monoclonal antibody given parenteral, binds to CD4 receptor/works as HIV entry inhibitor)

 

2 New classes of HIV Rx being developed:

1 HIV Maturation Inhibitors

2 HIV Capsid Inhibitors

 

Newer approaches to safety and tolerability in the future ART include:

Using lower doses of drug eg (EFV 400mg vs 600mg). Other studies in progress are ATV 300mg, DRV 400mg

Newer drugs eg tenofovir alafenamide(TAF). Switching TDF to TAF improved renal/bone markers

2 Drug regimes: PI/r+3TC (or FTC), PI/r+ integrase inhibitor, NNRTI +integrase inhibitor , DTG+3TC/Paddle Study(results showed VL all suppressed by 8 wks)

Less frequent dosing eg RAL daily formulation

New co formulations eg ATV/c and DRV/c

New injectable drugs RPV LA, Cabotegravir

 

Latte 2 study is looking at IM CAB +IM RPV with conclusions showing IM is comparable to PO and well tolerated. Phase 3 studies are evaluating IM q4wks.

 

Dr Gulick concluded by saying that future ART Rx will involve greater use of sub dermal implants and injections with potentials for dosing going from weekly up to every 1-3 months. Costs will radically decline and affordability improve. Convenience will also continue to improve. We have already seen the dosing levels of 20 tablets a day reduce to one a day in the last 10 years. Interestingly life expectancy in ART uses from recent studies in US, Canada and UK were showing higher figures than for the average population!  Presumably regular medical intervention can be a good thing for our species!

 

 

Tagged in: EACS 2017 HIV

The welcome to the conference was at 2pm…and I had already eaten so much “information” gelato I was decidedly full…however as with all good food (for thought).. there is always room for more…so I decided to sample the “Round Table: Modles of HIV testing and delivery of PrEP”

 

This session was opened by Prof Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot ) who highlighted some of the issues limiting or preventing the implementation of PrEP in Europe.  He discussed the cost benefit of people on PrEP versus the lifetime cost of treating those living with HIV and the distinct need to highlight PrEP's feasibility. He discussed the need for close partnerships with the community and political support to facilitate PrEP implementation.

 

Dr Emma Devitt from Dean St Clinic (also see Emma Clements post) highlighted their exemplary model of testing using cutting edge technologies to facilitate patient’s access, testing availability, results turn around and treatment options.  Amongst routine STI services, Dean St service provision includes on site laboratories, HIV and Hepatitis specialist clinics, HIV oncology clinic, Urology and dermatology services, Dietetics, Contraceptive/LARC services, Anoscopy, ED/Psychology/Psychosexual and a Pharmacy service. Most impressively to facilitate their ‘self-testing’ model they have guided self-sampling videos embedded in the mirrors in their bathrooms to guide clients through the process self-collected swabs.   Of course there was mention of the GeneXpert technology which provides extremely quick results turn around but what struck me here was the added option of a web link to the next available treatment appointment should your result be positive - its the total package of care!  Statistical modelling showed that since the introduction of the Express model at Dean St, STI’s are treated 8 days faster than previously and for every 2 people diagnosed with a bacterial STI’s one partner was spared exposure suggesting public health implications and cost savings.  This rapid STI diagnosis and treatment is thought to be one of the causative agents in the recent dramatic reduction in HIV diagnosis seen at Dean St.

 

Gus Cairns editor of AIDMAP and co-ordinator of PrEP in Europe talked through his personal experiences of HIV diagnosis in 1985 and why he is such an advocate for PrEP in the modern era.  He talked about 20 years of fear inducing messages when condoms were advertised as the only responsible way to have sex. PrEP had brought with it a reduction in the crippling anxiety that many MSM experienced during sex, in PrEP the protective behaviour is separate in time from the risky action itself and described it as ‘enhancing’ sex by reducing the fear. He went on to highlight that PrEP is not enough and in a powerful slide simply put the U=U message (undetectable=untransmissible) reminding me that we need to be confident and unanimous in this message.

 

 

Finally and to finish the session was a round table of questions in summary.  These addressed the following questions… How do we approach and include the young? How can we promote PrEP to wider audiences? Is there a future for over the counter PrEP?  Much like describing all the culinary experiences of Gelato tasting in Milan it is impossible to capture the sheer depth and flavour of the responses but needless to say I will find room for more taste sensations tomorrow!

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

ASHM ASHM