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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This year the HIV conference has been dominated by presentations on anal cancer in men who have sex with men, particularly those living with HIV.

A/Prof David Templeton presented the interim findings from the SPANC study, which assessed the utility of cytologic screening for anal cancer.

Dr Jason Ong presented an interesting overview of what clinicians can do currently to screen for anal cancer, given how little evidence we currently have on the usefulness of screening.

Dr Amber D'Souza presented on the epidemiology of anal cancer

Ben Wilcox and Lance Feeney presented on community perspectives and education on anal cancer.

Brad Atkins gave a moving presentation on his personal experience of anal cancer.

 

Perhaps the key messages are:

- Modelling has shown that anal cancer screening by a digital anorectal examination has shown it to be cost-effective only for HIV-positive MSM over the age of 25. In that scenario, it is currently recommended to perform anorectal examinations annually. However, an argument could be made to offer screening also to those MSM who are HIV-negative.

- Cytologic screening is problematic, in that it lacks sufficient specificity, resulting in a very large proportion of referrals to high-resolution anoscopy.

- We need to offer HPV vaccination to all MSM under the age of 25, and whilst there is no evidence of benefit over the age of 25 it would be reasonable to offer is to those MSM also (keeping in mind the cost to the patient).

- Much more work remains to be done to determine the best strategies to screen for anal cancer in MSM.

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

 

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

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

       

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

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

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

       

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

    1. Decreased anxiey

    2. Increased communication, trust, and HIV status disclosure

    3. Increased self-efficacy

    4. Increased sexual pleasure and intimacy

 

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

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

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

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

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

 

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

 

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

1. Obtain PBS-listing for PrEP

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

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