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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Looking at inequity and qualitative care data measures in UK for People Living with HIV min 2015, in the UK.

HIV – 98% diagnosed retain in care.

5-6 thousand new diagnosis yearly. 3,000 are gay men. 3,000 heterosexuals (people that acquired HIV abroad or late diagnosis, mostly new arrivals/immigrants).  

Most linked to care in first year of diagnosis

An early diagnosis in a high resourced country, shows similar lengths of life expectancy as the general population.

Many people feel (or experience) stigma and discrimination around social gatherings and settings.

Dental and Healthcare/GP’s are 2 areas the people living with HIV avoided.

 

Dr Gail Matthews, Sydney. HEP C Updates –

200,000 to 300,000 people living with HEP C in Australia.

2-3 thousand people living in Australia co-infected with Hep C and HIV.

Since the new Hep C Treatment begun 12% of the Hep C population.                             40,000 (20% of this Hep C population) expected to be treated by the end of 2016. Predominately genotype 1. Genotype 3 (less).

Updates to Census Guidelines for Hep C – 2016.

Gastroenterologists (Specialist) treatment rates have fallen to 50% with other Dr’s/Prescribers accounting for an increasing amount in March to June, 2016.

Possible Risk of HBV reactivation on DAA therapy. The risk levels are unclear. Prescribers can discuss with Specialist about Serology or treatment concerns.

 

CLOSING PLENARY - looking towards 2020!

President Elect Donald Trump accession in US and Global politics was discussed, with unanimous concerns of the possible impacts on marginalised groups, such as people living with HIV.

PEPFAR – is a major global initiative, assisting those with HIV/AIDS. It was thought funding may be less sustainable and diminished under Trump Presidency.

PrEP – Pharmaceutical Benefit Scheme - (PBS) Australia, hopefully rolled out next year. Need to target Aboriginal people, CALD Communities.                                                         There is an over-representation of ABSTI with HIV.                                                                     STI rates are climbing.  Condom use needs to remain as valued!

Partner with Aboriginal lead services to effect better outcomes for ABSTI Communities. Need high level engagement to focus on ABSTI chronic health conditions, mental health, HIV, STI’s and long term future funding arrangements.

ABSTI community lead primary healthcare in partnerships/collaboration with agencies.

Need better national co-ordination. Invite all stake-holders to assist in managing – Treatment as Prevention (PrEP) collectively.

Equitable care

Develop greater sense and involvement with communities.

Challenge the ‘spitting law’ that is been brought up by 3 states. This is NOT Evidence based practice. A motion agreed by all was held at the end of the Conference today.

Focus now needs to be on other priority populations, such as Woman and heterosexual males to be seen as a priority populations.

Develop internationally agreed best policy – basic guidelines of care and treatment.

There is a lack of engagement with governments and communities. This needs to change NOW!

Speak up and challenge funding cuts. We need to INVEST MORE.

Non-Aboriginal people to ‘speak up and be a voice’ for ABSTI plight and their needs.  

Migrants Medication and medical needs to be covered.  

Collaborate with local communities. How do we reach out to others less engaged?

What resources do we have and how can we mobilize them better?

Look towards Aboriginal Medical Service (AMS) for leadership in Primary Care delivery.  

Globally, The United Nations (UN) is under threats by been constantly undermined by States with vested interests.  

Next step in HIV care and treatment is a vaccine. Injectable is expected 4 + years away.

 

See you all in Canberra, ACT in November 2017 J

 

 

 

 

 

      

 

 

 

                           

 

 

 

         

 

 Aboriginal & Torres Strait Islander Health (ABSTI) – HIV & STI’s in the Australian ABSTI health context.

 Presented by A.Prof. James WARD and Prof. Gracelyn Smallwood and other eminent panellist discussed these contemporary health issues with Australia’s ABSTI people.

 HIV – double the rate of Non- Aboriginal people

                   With 60 % - Men that have sex with Men (MSM)

                             20% - Injecting drug users

                             20% - Heterosexual     

                                                                                                                                                               Please note that  -  20 % of HIV Diagnosis are Women and 12% live in remote and rural & communities.                                                                                                                                                                                                                                                       33% late diagnosis with 21 % having advanced HIV. In the general Population – 90% are diagnosed.

MEDICATION and adherence and co-morbidities are a huge burden.                               Mental Health/ depression – 12% report feeling depressed, with 9.6% of the general population report this.

The social determinates of health – ABSTI have poorer general health with unique challenges in addressing ABSTI HIV care and treatment. Medication burden.             Complex health.

 the effects of ongoing racism and discrimination.

 Feel “SHAME” and their spirits is low.

 Stigma from HIV.                                                                                                                                                                             Need to trust clinicians and respect for clients confidentially is utmost important.  

  

Needle Syringe Program (NSP) – 

ICE/Crystal has become a big issue.  

We can’t wait for an outbreak to occur, so we need to increase access to NSP services, such as in outreach programs.  

 Health and Community Partners/organisation to work with the community needs, in culturally appropriate ways, including not driving it (program & service health delivery) with experts  without consulting, involvement & input from respected key community stakeholders.

Partner’s organisations needs to ask local people to teach cultural norms. 

PANEL DISCUSSION –

90 % of the general population know HIV Status

80% of the ABSTI know their status (20% don’t!).

Reduced life expectancy (estimates 20 years compared to non-aboriginal Australia people).

need a grass roots approach, need to empower the local people by using their knowledge and expertise about their own local communities and support solutions at local levels.

Funding been cut by Governments with 75 % of Funding is going to non-grass roots, such as University Research & government bureaucracy.  

3% population in jail, 

                                                                                                                                          

food prices are increasing in local and remote communities 

Poor sanitation

No jobs, lack of career pathways

 

Cairns Doctors advised that the syphilis epidemic came first, then linked with HIV.  

Recently 1 female and 4 males (MSM) aged from 18-25 years HIV +                                  young mobile, homelessness (is a major barrier), couch surfing, staying with Aunties, not taking medication as forgets due to constant moving. Finances - Centrelink – cut off.

 Aboriginal Medical Service (AMS) – Aboriginal controlled services across Australia -      there can be an issue of taking blood in ABSTI Peoples.                                                          Non-Aboriginal Health care workers need to provide better cultural translations -           explanations as to why blood is needed (MEDICALLY) to be taken.

With young people there is a better acceptance of outreach programs that deliver rapid testing for Syphilis.  

Issues in screening STI’s in prisons

Aboriginal Community Health Workers – not getting paid and recognised properly.

Some Clinicians can be uncomfortable offering a HIV Test.

Clinicians needs to be flexible in care delivery. Work to ‘hold confidence’ with Clients.

How can Services be friendlier to ABSTI Peoples?

Building good working and trusting relationships is everything. Keeping rapport and people engaged.

Service providers need to become more effective!

Burden of disease/s, reluctant in accessing care, complex family dynamics, isolation.

Family worries, social issues, turning up for appointments and reminders.

Shame aspect – needs to be taken out of HIV. Of not having housing, which prevents people from becoming stable and stay on treatment.

 

 

 

 

 

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A.Prof. James. WARD - Aboriginal Health Perspectives.

A Predicted divergence of what is happing in Aboriginal and Torres Straits Islanders community’s in relation to HIV and STI’s.

  

New diagnosis of HIV in remote communities due to young mobile population.

Risk Behaviours such as sharing NSP Equipment, with a background of increasing prevalence of STI’s.

 Failure to engage Treatment as Prevention (PrEP) as need to take other medication (pill burden) for multiple health conditions/comorbidity.

 10-24 years age group, increasing Chlamydia and Gonorrhoea -                                                                  This highlights the inequities and lack of access to care.

 

Hep C – mostly transmitted through injecting drug use (IDU).  

Hep C has increased 43 % in 2011 – 2015.  

It effects the youngest 15-24 years old.

Hep C has 8 times the incidence in Aboriginal people (than non-Aboriginal People).

 

Rural and Remote Communities – need more access to Aboriginal Primary healthcare for testing and treatment and treatment as prevention (PrEP).

HIV in Cairns, QLD – young Aboriginal & Torres Straits Islander men in 2014-2016 had 50 % increase in HIV. This also effects bi-sexual men and men that don't dentify as gay.

NO access to NSP. Difficulties in approach to NSP and harm minimisation.

(Treatment as Prevention) TASP.

Prof. Ward said that we could learn from Canada’s first nation’s people in Saskatchewan that have a background of unresolved grief & intergenerational trauma. 

Increased of IDU and STI’s = HIV !

We need to prevent an outbreak occurring in our rural and remote Aboriginal and Torres Strait Islander (ABSTI) Communities. Health services are already limited and they would also not be able to cope with a major outbreak occurs. This would devastating to these communities.

ABSTI – vulnerability of population.

Need to increase the workforce in meaning work and career options

Need timely surveillance data, to be able to respond quickly    

Medicare to cover costs

Need to advocate ‘outside and ‘raise our voices’ (to Governments and the Australian people to increase awareness and be able to act/prevent). Especially non-Aboriginal People need to stand up and raise their voices about concerns and issues of our ABSTI People.

Increase the current low testing rates for HIV.                                                                                                                                                             Use a diversity/combination of strategies include - strengthen Aboriginal and cultural appropriate Primary care.

 Currently on 32% of people with STI’s are offered HIV Test. This needs to be offered 100%.

 Community itself needs to be interested and engaged.

 

 

 

As a nurse who has repeatedly encounter negative attitudes to PLWHA, by nursing students, I was looking forward to this presentation.

David Pickles presented research on the socio-cultural influences on the perceptions of nursing students toward caring for the people living with HIV/AIDS: Implications for Nursing Education.

Negative attitudes of nurses impacts patients. With the increasing number of overseas student, studying nursing in Australia, they bring with them beliefs from their home countries.

The interviews with the undergraduate students showed fear of transmission, myths & misconception, homophobia, responsibility and disparity. The quotes from the participants made it clear, some couldn't overcome their prejudice even with sound knowledge of HIV and its transmission.

The discussion afterwards was even more interesting, as different people spoke about how they had managed prejudice. Suggestions given included- calling out the prejudice, having PLWHA speak to students and having strong role models.

I agree with all the suggestions in the study and by the audience, but having worked in HIV for 20 years, I find it disappointing that we are still encountering this prejudice. When will the tide turn?

 

 

Two presentations. The first looked at the impact Lay Health Workers can make on male and female HIV transmission, contraception and ART take up in South Africa. The second looked at the effected of decentralising testing in Myanmar.

Low HIV Incidence amongst Pregnant and Post partum Women Receiving a Lay Health Worker HIV Prevention Intervention in South Africa.

Background

 

Each year 1 million woman in South Africa become pregnant. Of those 30% is HIV positive.

 

Study

 

Health Workers provide information, education and counselling to male partners. They also education on multiple partners, mental health, alcohol use, provide condoms as well as linking care for those found to be HIV positive. They offered circumcision for men HIV negative and referred them accordingly, as well as symptom screening of STI’s.

 

Outcome

 

There was a huge decrease in people needing treatment within the group, verses the background South African population.  Maternal HIV incidences 73-86% lower than previous studies. Community based HIV prevention was effective, and Health Workers were found to be highly effective.

 

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High HIV Positivity amongst other Vulnerable Populations Reached Through Decentralized HIV Testing and Counselling in Myanmar.

 

I found this presentation interesting, as it demonstrated how taking the test to the people is more effective than having the people come to the test. This will change my practice, as instead of providing information on where people can have a HIV test, I will investigate the possibility of having the test ready to administer to my patients.

 

Introduction

 

224,794 PLWHA in Myanmar live with HIV, which equates to 0.6% of the population. The key populations are People Who Inject Drugs, female sex workers and men who have sex with men. However HIV appears in other population groups, which are not being well serviced by the centralised testing program.

 

In 2014 HIV testing was decentralised. Since then, there has been a steady increase in testing. The number of people diagnosed with HIV steady decreased.

 

Results

 

There are high rates of stigma and discrimination towards PLWHA. High rates of diagnosis have been detected in miners, boarder regions, migrant works and mobile populations i.e. truck drivers.

 

Tailored services need to be developed to cater for the mobile population and increase access to testing for gold/jade miners.

 

 

I chose to review these two posters, as they both concern women, the first is about empowering through employment, the second is identifying the barriers to accessing services.

 

SEW Tanzania: Showcasing the Resilience of HIV+ Women in Tanzania. Lead author: Lees, N.

 

S.E.W. stands for Supporting Empowering Women, which is a social enterprise in Tanzania, which provides employment to HIV positive women.

 

The participants make conference bags from recycled wheat sacks and are provided with fair prices for their products. This shows them to be resilient, industrious and capable. By providing this work, S.E.W. seeks to end the stigma associated with HIV.

 

Examining the benefits to women living with HIV of a community organisation led research project. Lead author: Boughey, A.

 

Positive Women Victoria’s membership is increasingly becoming women born in Africa and the Western Pacific. They tend to be diagnosed later and often during their reproductive years.

 

The needs and preferences of this growing, culturally diverse population have not been effectively identified. With further research needed to identify the barriers to accessing services for the group.

 

 

Nurses on Placement: Primary Health Care Nurses undertaking Clinical Placements at Publicly Funded Sexual Health Services: Can it be done? Is it worthwhile? Lead author: Desreaux, C.

 

I found this poster very interesting, as STI testing seems to be limited to sexual health services and GP’s. If Primary Health Care Nurses were encouraged and educated to provide testing, would that increase testing rates? Also, how do I get a placement??

 

Introduction

 

The role of Primary Health Care Nurses (PHCN) is underutilised in sexual health care in GP settings. To expand their role, a pilot program was developed in which clinical placements at a publically funded sexual health service were offered. They were supported by mentors/supervisors, during the five half or full day observation placement. A series of questionnaires were completed by the participants and mentors before and afterwards

 

Conclusion

 

The program was well received by the participating nurses and mentors/supervisors. It is hoped that more support can be provided to the PHCN to undertake the placements and implement changes in the GP practice.

 

Elimination of Hepatitis C and HIV coinfection in Australia

 As Australian clinicians, policy makers and communities affected by hepatitis C march into a new era of widespread, accessible Direct Acting Antivirals (DAAs), Dr Joseph Doyle from Melbourne’s Royal Alfred Hospital gave a timely presentation about the feasibility of eliminating HIV/Hepatitis C Virus co-infection.

The global burden of Hepatitis C Virus (HCV) infection is massive at 115-130 million people. Australia shares a relatively small burden of these infections, with an estimated 230 000 people living with HCV.  Globally, 2.2 million people are co-infected with both HCV and HIV. Between 7 and 10% of people living with HIV have HCV, with their odds of acquiring HCV six times that of the HIV-uninfected population.

As with HIV infection and the familiar 90-90-90 goal-posts, the WHO has set ambitious targets for viral hepatitis. By 2030, WHO aims to eliminate hepatitis C transmission, with 90% reductions in incidence, and 90% of those infected treated effectively. This is expected to prevent 7.1 million deaths between 2015 and 2030.

To achieve this, health policy makers must address specific gaps in:

-       Testing

-       Access to care

-       Treatment, and

-       Prevention

To be maximally effective, testing must be sufficiently frequent among populations at risk. Early diagnosis and treatment scale up to the point where 80% of all new cases of HCV were treated has been modelled to drastically reduce HCV incidence. Testing must be available at little or no cost to consumers, and provide reliable results. In Australia, antibody screening assays are widely available in organized laboratories with excellent quality assurance. Gaps persist in the diagnosis and assessment of hepatitis C: the current requirement for Nucleic Acid Amplification Testing (NAAT), genotyping, and assessment for fibrosis each presents a barrier to treatment. Multiple visits are often required to plan effective antiviral therapy, and each step represents a risk for disengagement. Algorithms for laboratories to deploy reflex HCV Ag/RNA testing in the event of reactive antibody screens would be useful. When these factors are combined models suggest improvements in treatment uptake and reductions in HCV incidence.

For hepatitis C and HIV coinfection, injecting drug use plays a role in up to half of cases. In contrast to HCV mono-infection, sexual transmission is also important, particularly among HIV+ men who have sex with men (MSM). Modelling suggests that sexual behavioural change could dramatically reduce sexual transmission of HCV, but the challenges to implementing this in an era of reducing condom use are considerable. Linking testing and early diagnosis with harm minimisation is important, and in some cohorts results in reduction of IDU risk behaviour.

Rates of testing for HCV are currently good among people living with HIV. Victorian data suggest that PLWHIV are tested an average of 1.4 times each year. Consideration should be given to increasing the frequency of testing, but restriction of this to higher risk individuals seems prudent.

Access to care has significantly improved in Australia in 2016. PBS-subsidised DAA therapy became available in March 2016, and unnecessary restrictions on prescribing for able prescribers were lifted in November of the same year. Australia wisely and bravely avoided the temptation to impose restrictions to access DAAs based on fibrosis, alcohol consumption and ongoing drug use. These aspects have seen the proliferation of interferon-free treatment in Australia. Interdisciplinary collaborations that have embraced participation by hepatologists, infectious disease physicians, sexual health physicians, public health professionals, virologists, general practitioners, and community members have liberated hepatitis C treatments from hospital environments to the community where much wider, more acceptable, sustainable implementation can develop. The multidisciplinary Consensus Statement on hepatitis C treatment has been instrumental in facilitating community provision of hepatitis C treatment.

Effective antiviral treatment of hepatitis C is the cornerstone of hepatitis C elimination. Although the safety and efficacy of the current generations of DAAs have provided extraordinary advances in the treatment of HCV infection, further advances are needed. The development of well-tolerated, safe, efficacious, pangenotypic regimens that require increasingly less reliance on fibrosis status and previous treatment history would be beneficial.

Communities at risk of coinfection include people who inject drugs and men who have sex with men predominantly, but those born overseas in countries with hig prevalence of both infections should not be neglected. 

Cost effectiveness of interferon-free DAAs is well-established for those with advanced liver disease, but the cost of treating those with early infection without fibrosis is well within Australia’s resources. 

Harm reduction strategies around injecting and sexual behaviour are an important part of primary prevention, but also crucial in preventing reinfection after successful therapy. Treatment offers opportunities to collaborate with harm reduction agencies, and reinforce messages of risk minimisation.

Although no highly efficacious vaccine for hepatitis C has been developed, the public health role of partially effective vaccines should be considered. The role for such vaccines will depend on the degree to which prevalence is reduced. If treatment uptake is high enough to reduce the prevalence of HCV to very low levels, a partially effective vaccine is unlikely to be of benefit. In the setting of ongoing high prevalence, or of high reinfection rated, a partially effective vaccine may be of considerable benefit.

Just as the HIV Cascade from the Kirby Institute’s Annual Surveillance Report informs HIV public health practice, so does the HCV care cascade. Priot to the introduction od DAAs in the community, only 2000 people accessed treatment for HCV. The introduction of HCV DAAs saw 27 000 HCV-infected people being treated by the end of July 2016, representing 13% of all people with HCV infection in Australia. We are on track to providing treatment to 40 000 people by the end of 2016. This enormous scale up of treatment for hepatitis C is unprecedented, and is a globally important public health intervention.

Networking models for HCV acquisition among PWID are well-described. Higher connectedness to communities with high HCV prevalence of confirms intuition. The high level of connectedness to others with HCV suggests strategies for increasing effective uptake among  networks. Similar strategies might be effective among sexual networks of MSM in whom HCV is prevalent. ‘Bringing your friends in’ is potentially effective for both PWID and MSM networks, suggesting a singular effective strategy for co-infected networks.

To meet the WHO targets regarding reduced transmission, modelling suggests Australia must treat 4 700 HCV-infected PWID annually. To meet WHO mortality targets, 5 600 HOV infected PWID must be treated annually according to modeling. Given the uptake of DAA treatment in its first year, Australia is on track for reducing both mortality and transmission targets. Costs for achieving this are estimated to be around $7 billion, but prudent deal-making on behalf of the federal government is likely to achieve thi results for substantially less cost.

Reducing HCV acquisition among PLWHIV requires an understanding of the complex environment in which HCV transmissions occur. Factors include rates of partner change, condom utilization, injecting behaviour, sexual dynamics that include group sex an use of sex toys, and concomitant partnerships. Agency-based modelling, which accounts for such complexity, suggests a greater efficacy in HCV incidence reduction than compartment based modelling, and supports the efficacy of providing treatment to those with high risk sexual or injecting networks.

How can this be implemented? The Co-EC Study examines the utility of nurse-facilitated hepatitis C treatment in community settings. This study demonstrated that most people aith coinfection can be treated safely and effectively in community settings, providing that collaborative care is available when needed.

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In summary, there are many parallels between HIV and Hepatitis C treatment. Treatment cascades are informative for both conditions, and there are many primary and secondary prevention messages that can be shared with benfit between sexual and injecting risk networks. Australia is on track to eliminate hepatitis C and HIV coinfection with its insightful, innovative adoption of community-based direct acting antiviral treatments for hepatitis C.

'I speak more truth than the Pope'

Professor Gracelyn Smallwood is Professor of Nursing at Central Queensland University and Adjunct Professor at the Division of Tropical Health and Medicine at James Cook University (JCU), Townsville, Queensland (QLD). She is also a Birrigubba, Kalkadoon and South-Sea Islander woman who participated in a panel on Thursday 17th November at the Symposium on Aboriginal and Torres Strait Islander peoples - 90/90/90 - but who are the 10/10/10?

After Dr James Ward re-presented data on the more than doubling of HIV diagnoses amongst indigenous people in Australia in 2015, he said 'we are a critical point in the epidemic' and clearly need to act urgently.  The panel discussed proposals and strategies to respond to this dire situation, such as ways to get more people tested, diagnosed and into care.  Here I try to capture some of what Professor Smallwood said, as without such insights from aboriginal people and without action on these at a much higher political level, the medical, scientific and health professions cannot solve this.

Professor Smallwood, with decades of nursing and midwifery experience in rural and remote communities as well as in the city, and over 50 years of advocacy for her people, gave a clear and compelling response.   'We need to implement the National Aboriginal Health Strategy, Bringing them Home report and all other reports that have been written and not followed through'.  'HIV will be the last nail in the coffin' she said, and she has said this before.   'Locals are key.  We need blackfellas as chief investigators and aboriginal health workers are the key players, start empowering them, ask *them* to be keynote speakers . Get deadly health workers into clinics to undertake testing'.  Hardly any money gets down to the local level.  There's is a 200% markup on food (in remote areas), jobs have been phased out, it is no wonder people are using drugs'... 'Give me any disease', she said and 'I will give you the answer'.  

 

Quote shared by on in Legal and human rights, stigma and discrimination

I'll admit it now, I haven't been very up-to-date on the global approach to Hep C treatment, but this talk really brought me up to speed on several aspects.  Thanks to Dr Joseph Doyle for the great talk.

 

Global elimination targets

  • worldwide there are 2.2 million people living with HCV/HIV
    • compares to 37 million with HIV
    • odds of HCV infection were 6 times higher in people living with HIV
    • most HepC infections related to IVDU but some sexual exposure
  • target: 30% reduction in infections and 10% reduction in deaths (2020)

 

Elements needed for elimination

  • testing
    • early reliable diagnosis, frequent, regular testing
    • diagnosis allows connection with care and treatment, education, harm minimisation services, may influence at risk behaviour
    • Aust: recommends annual testing
      • but may need to recommend more frequent testing if we are serious about eradication
  • access to care
    • recent PBS listing to many new drugs
    • all are now interferon free
    • community prescribing is encouraged (after discussion with ID/hepatology)
    • no disease stage or drug/alcohol restrictions
      • in contrast to other countries where drugs are restricted to those with cirrhosis
      • this restriction would reduce costs but won't make much headway into eradication
  • effective treatment
    • sofosbuvir and velpatasvir (single pill regimen for all genotypes)
    • others are also coming soon
  • treating people at risk
    • target IVDU, MSM, born overseas in HPC
  • cost effective allocation
    • $20k for 4 years of extra life (if severe disease)
    • $60k for 6 years of extra life (if mild disease)
    • therefore even cost-effective to treat mild disease
      • many other options cost >$20k per year of life
  • harm reduction strategies
  • HCV vaccine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The medications are effective, the funding is there to support the clinicians, patients are enthusiastic and actively seeking treatment - I think this is an exciting time for Hep C management and I am optimistic to see the future.

The single-most incredible presentation at the conference.  Dr Kedar Narayan presented on some amazing new technology which is allowing us to view HIV in a completely different light.  He somehow managed to explain what is clearly a very complex principle in simple terms, and with plenty of humour sprinkled in.

 

  • traditional electron microscopy only provides a 2D image of the cell
  • focuses ion beam scanning electron microscopy (FIB-SEM) allows a 3D image
    • the tissue is embedded in a block, with the side face open to the EM scanning
    • the FIB laser is used to slice the tissue (like a deli slicer/cutting a loaf of bread) to reveal the next layer of the tissue
    • the EM can then image the 2nd layer
    • this is repeated 1000s of times to obtain a stack of images (like a CT scan)
    • computer software can generate a 3D image of the tissue, including all the internal structures
  • FIB-SEM can be applied to HIV
    • HIV virons actually use small tunnels from intracellular vesicles to the extracellular surface to escape the cell
      • this explains why other studies have found that the pH of vesicles were less acidic than expected (i.e. because they were actually connected to the extracellular membrane)
    • virological synapse
      • the dendritic cell actually “hugs” the T cell
        • rather than individual projections from the cell, the DC actually has lasagne like sheets (veils) to connect with the T cell
        • this excludes all drugs since the synapse is covered by the “hug”
      • often thought that the T cell is passive in receiving antigen presentation
        • not so - they can reach into the DC to sample for virus

 

What an exciting start to the day (following on from the excellent trainee sessions this morning), and the rest of the session proved equally as informative...stay tuned

HIV co-morbidities – are we measuring and responding them appropriately?

KEY POINTS

People living with HIV

-       Have increased frailty compared with the general population as they age calling for MDT/ holistic approach as a response [Jenifer Hoy]

-       More at risk of polypharmacy (>5 meds). Polypharmacy can lead to non-adherence, morbidly, Side effects, and interactions. The PAART study showed that >75% took >1 concomitant medication. The most commonly prescribed concomitant medications included lipid lowering medications, antidepressant, antiviral, PPI, anticoagulant, PDE5i, anti-diabetogenic and anticonvulsant. Many of these have serious interactions with ART. >700 interactions were found and 18.9% were on a CI regimen. Showing the importance of coordinated care, rationalising medications and regular good drug histories to prevent interactions.. [Krista Siefried]

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-       Increased risk of renal disease (historically due to HIV now shifting to ART and advancing age). Renal disease is associated with worse patient outcome and people with risk factors/ renal disease benefit from early intervention, screening and management. There are no guidelines in Australia that look at  monitoring for renal disease in PLHIV. However, there are international guidelines (EACS) that propose U&E and protein creatinine ratio (PCR) to stratify PLHIV into risk categories and then refer to specialist as appropriate. In a retrospective case review n=229 mainly male 30-39 with Low prevalence of known renal disease. Only 34% had PCR despite high prevalence of renal risk factors including smoking, HTN, HCV and low CD4/ high VL. Lack of simple urine dip signified a missed opportunity to pick up early disease/ proteinuria. Screening for renal disease fell below recommendations and should be considered in PLHIV [Tahiya Amin]

New approaches to HIV testing

Delayed HIV testing among men who have sex with men in Australia has improved but remains an issue – Huachun Zou

KEY POINTS

 

·      Delayed testing (testing less than annually) in MSM has improved but there is still some way to go

·      In Australia it is predicted that there are approximately 12-33% of people living with HIV who are undiagnosed

·      2/3 MSM consistently report testing but less than 40% return to be retested within 1yr

·      If all MSM were tested as recommended (every 3-6 months), modelling predicts there would be a 14% decrease in new HIV diagnosis

·      However, surveys have shown that only 1/3 are ‘very likely’ to increase testing levels. Many MSM don’t test annually and those at higher risk (5 partners in 3/12, >20 partners in 12/12, having had an STI in 2y) tend to be the most unwilling to increase testing.

·      ACCESS data from 2007-2014 from 24 sexual health clinics showed those more likely to test >p.a were under 25. Only 36% of high risk MSM tested annually and only 2% ATSI.

·      Amongst those at high risk delayed testing has improved from 75% to 69%, with delay in testing being more likely if ATSI, this was statistically significant.

·      In conclusion delayed testing is still common in high risk MSM especially if older or ATSI

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·      Strategies to improve testing further could include ?home based/ self test HIV testing, 3/12,  sms reminders (shown to work), computer alerts in GP practices and guidelines on testing (also shown to work).

Stigma and discrimination in Timor Leste - Ines Lopes, Executive director, Estrela+, Timor Leste.

KEY POINTS

·      Timor leste  a catholic, spiritual and ‘moral’ based society.   

·      631 cases of HIV. 231 on treatment (75 deaths) – considered low prevalence

·      ESTRELA+ Aims to allow people living with HIV to live with dignity/respect free from discrimination  through community based teaching in response to challenges faced due to conservative nature. HIV taboo, cannot mention sex, ‘moral’ attitude promoting immoral attitude to those living with HIV. This leads to people living with HIV not disclosing status to healthcare/ employer

·      ESTELA+ fund misinformation was widespread with media playing a significant a role in perpetuating this. It was found that Stigma could be extreme and revolved around HIV being seen as an ‘immoral’ or ‘bad’ disease. Some stigmatising behaviour included being called ‘dirty’/ shouted at/ violent threats/ forced to move/ rejected by family/ medicine thrown away by family/ prevented to visit healthcare/ baby removed by family.   

·      People living with HIV had concerns with regards to lack of confidentiality and differential treatment in health care. This meant people living with HIV were more likely to use free foreign clinic as they felt that they had better treatment and confidentiality was respected.

·      Change continues to take place through solidarity and support, lobby the government  with regards to labour rights. Community groups have worked with the church to promote tolerance and work  has been done at a community level to disseminate evidence based information and community training.

 

Perceived stigma is associated with non adherence to ART; a case study of a community- based sms reminders campaign - Limin Mao

KEY POINTS.

·      Trial of 6-week intervention of community driven sms reminder/ congratulatory sms to assist with ART adherence. It comprised three groups:  G1- 2 way sms 3/wk, G2 - 2 way sms 2/wk, G3 - 2 way sms 1/wk.

·      Valid responses – roughly split between 3 groups.

·      Characteristics included 85% Gay men, 25% outside metro area. Many lived alone without a partner pointing towards an otherwise isolated cohort.

·      34 with CD4 >500  - 11 increased, 2 decreased, 18 stayed same  (no statistical significance found)

·      During intervention (last week) 100% adherence. And adherence increased across all groups throughout the intervention.

·      Participants felt no stigma from non-adherence but  did report stigma related to: HIV status (31%), sexual orientation (27%), drug use (11%).

·      Participants reported majority of support came from  HIV clinician and HIV support groups.

·      Participants liked a community based reminder/ congratulatory message when adherent as it made them feel supported. They preferred receiving a message from the community as felt clinicians too busy and fear of letting clinician down if non-adherent. It was noted most already had strategy in place to assist adherence 

·      Sustained ART adherence is required, PLWH want community based support.

·      Future studies would need to look at if SMS reminders would be tolerate on a long term basis or more suited to initiation of therapy/ if having difficulty being adherent.

 

Development of a national monitoring system of stigma among people living with HIV in Australia - Carla Treloar

KEY POINTS.

·      The stigma indicators project  - was a brief indicator of stigma and measure of stigma over time including the mirror of stigma/ attitudes of healthcare professionals over last 12 months.

·      Results 200 ppl (>50/male/ gay /1% ATSI/ 5% CSW/35% PWID)

·      Almost all disclosed status to healthcare/family – fewer to employer/colleague.

·      Stigma most frequently experienced in media, amongst healthcare workers not paramedics and sexual partners.

·      Internalised stigma observed in 25%-50% - proving a significant experience for those surveyed.

·      1/3 – 3/4 reported they had been told by others that they had felt stigma from sexual partners.

·      In conclusion the preliminary data from ‘The stigma indicators project’ includes – stigma and discrimination most common sexual partners health worker and media.

·      Future work will covariate i.e. mental health and develop qualitative work with CSW and HBV and feed these results back to the national strategy.

 

ART use, stigma and disclosure changing attitudes among PLHIV 1997-2015 - Jennifer Power.

KEY POINTS.

·      FUTURE study

·      PLHIV Self reported physical health–good/excellent, general wellbeing good/excellent and this is consistent.

·      However, attitudes toward relationships and disclosure showed increase in concern over disclosing status, a consistently high preference for sero-sorting and a reduction in fear of virus transmission reduced,

·      FUTURE STUDY also revealed High rates of diagnosed mental illness (>50%), with 30% taking medication in last 6 months this mainly consisted of the 45-59 age group.  There was no sig difference between men and women.

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·      In conclusion, wellbeing study for PLHIV requires more than purely medical treatment and issues of stigma persist despite improved health/ viral suppression.

 

What PrEP means for safe sex in Sydney: evolving norms - Bridget Haire

KEY POINTS.

·      Bridget Haire discuses UNSW Qualitative study investigate how PrEP is affecting sex cultures amongst gay men on PrEP either privately sourced or on clinical trial, through interview and focus groups with gay men  and health providers.

·      Common themes discussed included: -

o   A new stigma evolving towards condom users that ppl not taking PrEP/ using only condoms are uninformed and condom-use lowers sexual capital.

o   Attitude towards STI’s includes a strong framework around testing and treating rather than condom use, accepting condoms not perfect and maintaining a strong community context.

(There remains a controversy amongst healthcare professionals as to whether there is a real increase in STI or just increased testing).

o   Attitude to Undetectable Viral Load  - polarised to ‘want to see it in writing’ to only asking if on medication or not.

o   Sex anxiety – PrEP has reduced sex related anxiety around HIV transmission.

·      In conclusion PrEP didn’t precipitate condom less sex as condom less sex predated PrEP but it does seem to be reinventing the idea of  ‘sexual citizenship’ (‘sexual citizenship’ first described by David T Evans in 1993 as the rights and responsibilities around ones sexual career). It seems a new stigma evolving with sexual rejection of condom users. This tension between PrEP and non-PrEP users needs to be addressed to develop the idea of that a combination of health promotions can reduce HIV.

·      The Implication is that health promotion needs to be embedded in the conversation that communities have in order to be relevant.  Future studies need to follow theses attitudes/ trends over time.

Day three Australian HIV/AIDs conference 2016  

 

Towards elimination:  parallels between HCV and HIV models of care – 

Joseph Doyle, specialist in infectious diseases and public health medicine.

 

KEY POINTS

•Australia has 230,000 cases of HCV, a relatively low prevalence. This consists mainly of PWID but also a      significant proportion who acquired HCV through sex, especially if HIV pos. 

•WHO 2020 targets aim for a 30% reduction in  new dx of HCV and a 10% reduction in deaths from HCV.

•To ensure success those at risk need access to frequent, regular testing to ensure early dx, with early dx leading to early connection to care. Australian guidelines recommend annual HCV testing for those at risk (or testing associated with a specific risk) and once ever testing for the rest of the population. 

•Testing programs need to be considered – as antibody/PCR testing take two visits, Genotype will hopefully be made redundant and liver disease test such as fibroscan – not required for people with APRI<. Rationalising testing reduces time required to treat. Rapid RNA and annual testing in PWID  - will help to meet WHO target. 

•Improvements in treatment have been due to highly effective treatment available on PBS (the near future will see a single pill regardless of genotype). Community prescribing (unique to Australia and supported by specialists), no disease stage restrictions and no need for fibroscan.

•Elimination is more likely if treatment is targeted to PWID/ MSM/ Overseas born (due to a small element of vertical transmission from more high prevalence countries). 

•Treatment of PWID has been shown to be effective/ safe/cost effective and can be given in conjunction with harm reduction strategies such as OST, NSP and peer support to increase the likely success of treatment and prevent reinfection.

•A scale up of treatment to 40/100 PWID p.a could halve HCV prevalence in 15 years and using injecting network data/bringing along injecting partners could reduce prevalence by 85% parallel to new dx HIV contact tracing .

•Other strategies include potential vaccines that even if only partially effective can still impact the epidemic in high prevalence area’s. 

•To achieve the mortality target those with advanced disease will need to be targeted, this can also be achieved by treating PWID due to new HCV cases prevented.

•In conclusion, to meet WHO targets of HCV elimination and reduced mortality testing and treatment will need to be targeted and include injecting networks. Rationalising tests and simplified effective treatment can go someway to achieving this goal. 

 

Day 2: A Changing Sexual Landscape of Gay Asian Men in Sydney: Implications for HIV/STI Prevention

 Day 2: Rapid Fire Session Sexuality and Reproductive Health:

Tim Chen – Asian Gay Men’s Project Officer ACON NSW ‘A Changing Sexual Landscape of Gay Asian Men in Sydney: Implications for HIV/STI Prevention’.

Tim discussed the results from a survey conducted between September 2015 and June 2016 for Asian gay and bisexual men.  The survey was printed in English and Thai languages and conducted at sexual health services (including a[test]), sex-on-premises venues, forums, workshops and through partnership networks.  Some similar research had been conducted in 1999 and 2002 and it was decided there was a need to repeat this survey due to the rising incidence of HIV and STIs among Asian MSM. 

The survey this time round was more ethnically diverse than previous years .  Although the overall number of Chinese respondents did increase compared to previous years, the proportion of Chinese respondents decreased and a greater proportion of Thai, Indian and Filipino guys completed the survey.  

HIV and STI testing rates had increased but less guys were testing at GPs with increased rates of testing observed at community-based testing sites (eg a[test]) and hospitals.

In regards to condoms use, guys reported less anal sex with their regular partners but similar levels of condoms use with these regular partners.  More anal sex with casual partners was reported than in previous years with more condomless anal sex.

In conclusion, sexual practices and health-seeking behaviours have changed among Asian MSM in recent years with an increasing rate of condomless anal sex with casual partners (it is worth noting that this study took place before the commencement of the EPIC PrEP trial in NSW).

Community-based testing sites were also shown to be of great importance in ensuring high rates of HIV/STI testing in this population.

 

Presentation by Andrew Carr.

Bone loss in 1st year of ART is a well established fact.

Loss is more on tenofovir containing regimes 2.4-3.8%  non tenofovir 0.7-2.5%.

Compare to 1 year 10mg prednisolone 0.8 -3% loss

PREP tdf-ftc

4RTC's show 0.5-1.5% loss BMD over 12-30 months!

          Reversible  if stopped  after 1 year

             Reversibility not established for longer periods, prep may be long term

Proportion of those with greater bone is uncertain

            >3% loss at hip and LSS in 25-50%

Non adherence issues in early RCTs , so bone loss may be underestimated.

Study 36 men taking TDF-FTC PrEP on prelude trialNSW,av age 38, av weight 79.9,TDF exposure pretrial 6months.

Average BMD loss - 2.2 spine,-2.5 fem neck,but,approx 45% lost>3%, 25% lost>5% BMD

Study limitations :no control,no women,some loss attribuible to age, 1 year data only,no PK data

Needs:

Longer f/up, data on secondary causes of BMD loss,more patients to identify risks for the greater loss group

 

 

 

 

HIV and the law – a consensus statement

Paul Kidd from the HIV Legal Working Group (VAC and Positive Life VIC) launched a recently published consensus statement about HIV and the law at the ASHM hub during the afternoon break on Wednesday. The consensus statement was written by leading HIV clinicians and scientists and was published in MJA on the 7 November. 


Paul Kidd provided context around the development of the statement and an overview of the key points covered in the statement.

Context
There have been at least 38
Criminal cases related to HIV transmission or exposure in Australia and the rate of prosecutions hasn’t decreased with advancements in treatment and prevention options. HIV-related criminal prosecutions require that legal professionals interpret scientific evidence on HIV transmission risk and the harms associated with an HIV diagnosis. History indicates that scientific concepts may have been inconsistently applied in Australian trials and some people have received very harsh sentences (arguably too harsh).

 

Recommendations
The statement outlines the latest evidence on HIV transmission risk, prevention and treatment. The main points covered in the statement:

       The risk of HIV transmission during sex is very low (and may have been overstated in HIV-related legal cases in the past).

       In addition to condom use, the following should be considered as taking reasonable precautions to prevent transmission:

o   If an HIV-positive partner has an undetectable viral load OR

o   if the HIV-negative partner is taking PrEP

       Phylogenetic analysis cannot prove causation in HIV-related cases.

       Most people living with HIV are able to take simple and effective treatment and will have a normal life expectancy.

 

The statement recommends:

       Legal cases relating to HIV transmission should consider the best scientific evidence on HIV risk and harms

       Alternatives to prosecution, such as the public health management approach, are often appropriate

 

Paul thanked the impressive contributors for their authorship and the wider working group for their commitment to the statement. I was lucky enough to be involved in the development of the statement and it was great to be present for the launch.

 

The statement is available on the MJA website at: https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement

 

A PDF is available on the ASHM website:

http://www.ashm.org.au/hiv/resources 

Brief video created today to help increase knowledge for GP's on DRE exam for MSM.

I hope that it will help increase knowledge and practice within the GP community. I will continue to share response from my GP colleagues as they interact with the video.

Very excited to be able to walk away from this conference with some proactive resources that may help increase knowledge beyond those who attended.

Specail thanks to Dr Ong for this time and expert knowledge.

Learn more here: http://www.anal.org.au/clinician