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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Associate Professor Rebecca Guy gave the Gallows Lecture.

The theme was new technologies for STI prevention and adult health checks with the target populations

- Aboriginal and Torres Straits Islanders People, 

- Gay men, 

- Mental health 

 

Resources and Notification of Partners. SMS technology is preferred. 

23% notified partner/s

Only 1/5 followed up in a clinic 

www.letthemknow.org.au

www.thedramadownunder.info

HOW is this going to change and effect my PRACTICE?

I will incorporate more IT into my clinical practice, as the Research has shown that clients and patients prefer SMS technology.  I have found this to be more effective approach in contacting those less engaged and harder to reach Clients, as it appears to be less intrusive means of contact & provides people the choice of when they want to make contact.

 

Other presentations on sexual health - Chlamydia 

Discussed health seeking behaviour. 

Focus on Adolescents

Low testing rates, 20 % people became re-infected in 1 year.

Issues are PID, infertility.

Gay men, increase risk HIV 

www.access-study.org

 

 

 

The presentations from the HIV Diagnostics Conference have now been put on line. They are accessible at

http://hivtestingconference.org/2016-hiv-diagnostics-conference/oral-presentations/

You can access the full program from this link and simply click on the desired presentations.

Those who pay much attention to the HIV testing landscape in the USA will be aware that there was a long period where the testing algorithm was debated, discussed and reviewed, resulting in the 'New' algorithm coming into effect in 2014. At this conference it was suggested a number of times that the new algorithm should now be redrafted.

Largely the reason for this is the shift in treatment guidelines and the relationship between testing and treatment. The 'new' guideline was written against a background of selective CD4 and viral load based decisions about when to start treatment. Now, with the emphasis being on starting people on treatment as soon as feasible after diagnosis, the need for repeat testing was questioned. This is an important shift, where one can see treatment and clinical practice driving precursor testing. These issues are discussed in 

Session C: CDC/APHL Laboratory Testing Algorithm and 

Session D: CDC/APHL Laboratory Testing Algorithm (Part 2)

There was a very good round table discussion on Wednesday morning which looked at matching testing approaches to the HIV cascade. Joanne Steckler raised the issue about the large differential between people tested and people lost to follow-up. This comes from work in Washington state, where a great many people who were thought to be lost to follow-up were in fact legitimately in care somewhere else, often no longer in the county or state.  

At the same time, rapid tests, which have been widely used in the USA for many years as part of the testing strategy, particularly in community settings, but also in more remote areas (Alaska, Midwestern and north states) where laboratory access is limited, are becoming less popular.

One of the major reasons driving this is the problems associated with false negatives. As always there was some discussion about the amount of transmission associated with very early infection, and it was interesting that there was a greater linkage between efforts to get people to test, particularly very early after infection, and recognising the limitation of point of care or rapid tests in these contexts. 

Session F: Performance of CLIA-Waived HIV Tests and the session immediately before this examined some of these issues.

Testing was very much seen as the vehicle facilitating the linkage of patients to care. A presentation from Eugene Martin, New Jersey, demonstrated that high level linkage could occur with timely intervention.

The laboratory instrument providers also attend this conference. It seems that many of the analysts have the capacity to perform multiple tests (concurrently, but not yet necessarily all the tests we would like to see in the one run). But this really did seem the next step where the largest leap could be made. This particularly emphasised the need to link HIV testing with related testing in the STI and viral hepatitis areas.

The closing remark gives a good coverage of the scope of the meeting. It was thought there was ongoing need for the meeting and that it would have to, in the context of HIV PrEP, include STI in its agenda. 

 

 

The Conference opened with a broad based plenary looking at the new landscape in HIV, often referred to as the HIV Testing 101 Workshop. This is a two hour session which will be on line shortly and really is an excellent overview. It starts out with a glossary of terms and then moves through technology; performance; programs; surveillance and the relationship between laboratory and strategy.

I strongly recommend that anyone setting out into the world of testing watch this session. The slides will all be up on the website some time after the conference and we will advise when this happens.

The USA has recently introduced a change algorithm for HIV diagnostic testing. This raises practical issues for laboratories. But an equally important issue for this conference is how laboratories support initiatives to increase testing (and timeliness of testing) and improve the care continuum.

Details can be found on the website http://hivtestingconference.org  

Key HIV Testing Issues

Key issues in this meeting are how to get testing done early enough and also how to use the best test on an early-after-exposure sample. This will likely play out over the next few days. Clearly the cognitive distance between the laboratory and the clinic is narrowing here. Labs are trying to play a role in the clinical improvements that are sought in reducing the time between exposure and testing. Yet with the increase of self testing, and large scale community clinics with the capacity to perform more complex tests, the laboratory is coming much closer to the community.

With this comes the big question for me: How does one get this information to the person needing testing, at the time that they need it? The Achilles heal in any algorithm would seem to be the differentiation of the population upon which it is performed.

Joanne Stekler (Seattle) discussed this in the breakfast session today. Indicating that the greatest variation between yield on different tests is how differentiated the sample is.  Population-based screening is low yield in low prevalence settings and yield rises dramatically when more targeted testing is performed.

Increased infectivity during seroconversion and early in infection mean it is vitally important to get people to test during this period. Though this has not been discussed here yet, the role of PEP in this context should be reconsidered.

 

 It is known that combined  Antiretroviral therapy(cART) before 6 weeks of age results in low levels of HIV .

If treatment starts before 1 year of age, there is a median of 4 copies at 10 yrs of age.

Treatment within first 48 hrs(& first 4 days of life), most will clear the virus before 4 months. Most of the virus is in transient memory cells, rather than central memory cells. The Missisipi baby was infected in utero but treatment was initiated within 31 hrs and discontinued at 18 mths. This baby remained in remission for 28 mths off cART.

Very early cART alters HIV persistence in children. It limits pro viral and replication competent reservoirs.

In adults, we are still determining what undetectable HIV (when being treated with ART) really means., and how early is the ideal time to start treatment.

In HIV infection, there is a massive expansion of HIV in lymphoid tissue but with treatment it is undetectable in the bloodstream. There may be decreased intracellulardrug concentration in lymphatic tissue And this may be the site of clones that expand when cART is stopped or if there is poor adherence to ART medications for whatever reason

This symposium provided a great analysis of some of the issues confronting prevention efforts. Julie Overbaugh gave a great overview of HIV biology, particularly that period of time known variously as HIV stage 0, pre-seroconversion and/or early infection. She emphasised that this was the period before viral-load peaks and a time where it is very difficult to study what is happening in humans as they are not aware they are infected. Macaques provide the study model, but given the complexity of this period even slight differences between the hosts and the viruses might introduce great variation. So with that caveat she explained that there is considerable dissemination of virus int he first 1 - 3 days and by days 3 - 7 the reservoir is establishing in gut and lymph nodes. The impact of prevention diminishes as the reservoir is established.

She also suggested that there is selective pressure not just from the dominant virus but that CCR5 is more common in transmission that CXCR4 virus, making R5 inhibitors logical for PrEP. CCR5 virus is also more resistant to interferon, which is produced in a storm during infection. She lastly she compared cell to cell infection and cell free virus, and suggested that infection may be facilitated to hindered depending on whether cell to cell or cell free viruses are the target. Meaning that what drives transmission in breast feeding for example may be very different from what is important in vaginal transmission.

Christophe Fraser discussed phylogenetics and gave a detailed analysis of comprehensive sequencing of virus in the Netherlands. He suggested that about 69% of new infections were originating from the undiagnosed and ~24% from diagnosed but not on treatment and only 7% from people on ART. Immediate treatment could be expected to result in a reduction of between 25-30% of transmissions. PrEP and treatment might result in a reduction of 50-60% of infections, summarising that there is a lot to do to push prevention beyond where we are now.

Richard Elion building on the this reviewed optimising ART and looked at Treatment as Prevention. He made the statement that "we can't just treat our way out." He suggested that we need to better know where infections are occurring in populations and compared the treatment cascade between a number of countries. But to illustrate this point he then dissected the 19% of people with HIV in the USA who are estimated to have suppressed virus a number of ways: 6% of people under 30 and 28% over thirty; 16% black MSM and 34% Caucasian. He also questioned some of the definitions within the cascade. and challenged what was meant by "in care" when 74% are in continuous care while 26% are in only sporadic care.  He ended his talk by looking at how to engage the unengaged and identified: stigma, delivery methods, integration of bio-medical approaches and resourcing as the critical issues. This led seamlessly into the last talk.

Jeffrey Crowley looked at HIV criminalisation and suggested that laws are not protective, even though law makers might want them to be. And in places with a high prevalence it is unrealistic to expect the assumption of negativity. He pointed out the important role of health care workers in educating about HIV and pointed out that provisions such as anti-discrimination legislation are not sufficient alone to remove stigma.

Australia was referred to in the questions. A country which has excelled in the response but which is still seeing sustained incidence. The strong take-home message from this session was the importance of biomedical prevention to interrupt the the establishment of infection. This will challenge many attitudes but it may, in combination with treatment and testing, be the only way to significantly reduce new infections, particularly in settings, such as ours, where retention in care, treatment and viral suppression are approaching their maximum potential. 

The session was symposium S-5 4.00 pm - 6.00 pm Wednesday Advancing HIV prevention. You can view it from the webcast http://www.croiwebcasts.org/

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

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