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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Great session today on rectal Chlamydia today that will definitely change the way I practice.

Rectal Chlamydia can be difficult to treat with increased resistance to Azithromycin (1g stat dose = 86% cure)...

99% cure has been noted with Doxycycline 100mg BD for 7 days.

Question is should this change my practice?

For me the answer is perhaps..

If compliance is an issue it may be best to do 1g Azithromycin and then test for cure. Have Doxycycline in backup for failure.

In severe symptoms and/or the patient is likely to have good compliance I thing I will change to the Doxy regime, also with test for cure...

 

 

Posted by on in Public Health and Prevention

Plenary 2 Tuesday 15/11/2016

GOLLOW LECTURE :Rebecca Guy Assoc Professor Kirby Institute:surveillance,evaluation and research program

Presented new technologies for STI  Prevention

Re thinking Sexual Health 

And how can we use new technologies for disease prevention

Specifically Information technology

To embrace what people are using therefore currency

In a world open 24 hours

 

Primary and secondary prevention:STI testing and diagnoses

What technology has been evaluated

PROBLEM: STI Testing;time consuming/registration 

Solution electronic client self register:self appoint

Outcome evaluation significant benefit re time saved

Problem of awkward conversations 

Solved by computer assisted survey instrument (CASI) 

Linked with management system

Evaluated as efficient, acceptable,

Problem of STI test with clinic capacity

Solution Xpress clinic

Evaluated 

All leading back to reflection and constant need to improve efficiency of practice and improved outcomes for clinic and client

GP still low STI  testing rates despite 80% young people go to GP

Latest findings suggest poorly targeted

ACCEPT survey:

150 GP clinics

73.4% of chlamydia presentations asympto clients attending for non sexual health issues /missed opportunistic test

.? COMPUTER PROMPTS 

Evaluated and helpful 30% increase testing

Need comprehensive screening eg previously rectal swabs not done MSM

User friendly software

Low Syphilis   testing in increasing STI rates

Solution:opt out/opt in syphilis test in HIV management

Simple cheap study in 2007 by DR Melanie Bissessor and MSM with HIV

Simple sticker on file requesting syphilis check

Pre 21%

Post 85% :such simple cheap intervention.

Study 2

Syphilis testing same day as HIV VLautomatic,could deselect:

Colaboration required clinics, labs under Burnett Istitute

ACCESS checks how tracking

Generally need to increase testing rates

Problem of treatment delays especially Remote areas

Discussed SMS reminders recall possibilities

TTANGO (test treat and go);Colaboration 12 Health Services

Key message is the mean time to treatment

With POCT 4/7

Lab test 19/7

And partners to be treated

Use of "Let them know"websiteMSHC, evaluated/acceptable:SMS

BUT people not returning TOC, reinfection and dangers PID etc

Discused other clinical strategies and efficiency eg: REACT RCT:

Not suitable for test kits mailed to address parents,partners

Other technologies not comprehensively evaluated

WA online educational resources parents and adolescents

Poor condom use reported: Adolescents report "no condoms it just happened"

The new world of online websites to meet and connect and how to tap into that population group to encourage testing

The difficulty of behavioural interventions

Technology must help research ,rapid info to inform  progress

data.kirby.unsw.edu.co JUST released

TAKE HOME MESSAGE

Why not all Health Services using IT/online technologies 

Is the future online Sexual Health Services.......

Need to all look at improved, efficient, acceptable and cost effective ways of increasing comprehensive STI I testing

 

Christopher Fairley  MSHC presented

The use of nformation technology to improve Sexual Health care in a following session

Which complimented Rebeccas presentation

Great comment; Health care is most important fight against STI

STI easier to control than treatment

Sexual Health does not deal with "noble organs" does not attract the $

need to be more efficient....like the Banks....

Need IT in clinical services

CAS:I :all staff  and clients love it

Use of SMS

Websites like Let them know

STI Atlas

Whats PREP

DATA OPENS EYES

CLINICIANS NEED TIO UNDERSTAND DATA

NEED A DATA BASE

 

Sexual Health Day 2 Pharyngeal Gonorrhoea

Very interesting presentation of transmission of pharyngeal Gonnorhoea.

Take home points:

  • Not likely to be transmitted penis -> throat / throat -> penis as commonly thought.
  • Likley transmission mechanism is via saliva. Deep kissing and use of saliva as lube
  • Pharyngeal Gonorrhoea may be more prevalent in younger age groups due to higher levels of kissing
  • Worth rendering to ensure swab of throat even if clients report no oral sex 
  • ?could anallingus be a mode of rectal transmission?
  • Daily antibacterial gargle may greatly reduce load of pharyngeal Gonorrhoea

Professor Mark Hayter University of Hull

"Stronger Than The Sum Of Our Whole"

Notes: 

  • The one stop shop can be a great opportunity to offer comprehensive care for clients with multiple needs.
  • Great chance to consider combining sexual health and reproductive health, sexual health and drug and alcohol services.
  • Colocation within schools may be useful and a great chance to "be where the market is". Evidence points to importance of need for concominnent quality sexual health education as well as branding as "health" service rather than "sexual health " service to reduce stigma.
  • May not apply to all markets, ie gay men appear to prefer traditional GUM/Sexual Health services.

Personal reflections:

My question is, isn't the GP in the perfect position for this? I wonder if there are GP's similar to myself who feel strongly to be able to step up and provide these levels of services. 

Currently this reflects my own practice however I wonder if there are other GP's who have similar passions.

Will these services limit communication between teams and loss of some patients to primary care?

 

Sexual Health Conference Day 2  Gollow Lecture IT and sexual health

Notes: 

Young people are very engaged with new technology. 

  • It's available 24/7
  • Offers privacy
  • It can be interactive
  • Is able to offer sexual content.
  • For me it's highly valuable for education

New self check in stations have proven to increase efficiency with faster interactions, data being more accurate as well as allowing more patients to be seen.

Other interventions include medical software prompt systems which have proven to increase opportunisitc testing of STI's such as Chalmydia.

Computer system grouping of tests and guidance has also increased syphilis testing in HIV positive clients and checking for missed tests such as rectal swabs for Gonorrhoea / Chlamydia in MSM.

SMS recall systems have increased testing regularity and recall for test for cure.

Resources:

http://amaze.org
http://data.kirby.unsw.edu.au

 

Daniel Richardson talked about the increase in sexual transmission of HCV and who to test and when.

A very brief overview of when to screen:

* For heterosexual couples: linked HCV transmissions rare and screening for HCV not recommended

* For HIV positive MSM: HCV transmission associated with increased sexual partners, syphilis, condomless anal intercourse, group sex, chem sex and practices such as fisting.  Screening is recommended annually

* For HIV neg MSM the risk factors for sexual acquisition of HCV are similar to HIV positive MSM 

Screening is not recommended for HIV neg MSM without the above risk factors 

Annual screening is recommended for HIV neg MSM with the above risk factors, and for those who are using PrEP

What a great session!! 

The importance of STI screening post sexual assault, the relevance and role of technology in violence, and the great initiatives in response to violence in Aboriginal communities. 

My future practice will definitely change to incorporate conversations around violence to both potential victims and perpetrators of sexual violence.  Often questions are not routinely asked of potential perpetrators regarding behaviors that are unacceptable. 

Incorporating technology and its potential risks has been highlighted as an often forgotten element of health and sex education to the younger generation. Emphasizing the risks of private photos and events being shared needs to be stressed when delivering health education in an attempt to encourage people to think about the potential consequences before sharing photos or film clips seems simple, however is frequently not discussed when delivering education. 

Great presentations by everyone and very moving personal stories shared. 

Day one of the Australasian Sexual Health Conference 2016 included presentations showing: advances in resistance testing and POCT for common STI’s, novel treatments of MG, possible reasons why Australia lags behind in LARC uptake, Australia-specific barriers to termination of pregnancy, as-well as issues such as the importance of a multi-layered representation of aboriginal men to aid with engagement around sexual health and how policy is protective of LGBTIQ young people in Australia.

 

Associate Professor Rebecca Guy discussed the challenges of STI testing amongst aboriginal communities in remote areas. She reported the average time to treatment being 21 days due to population mobility and distance to lab, with 1 in 5 not receiving treatment at all. 

In 2011 12 rural health services trained aboriginal nurses and health-workers to perform a POCT for CT/NG (‘Xpert’). This meant results could be given within 90 minutes. Treatment uptake increased to 96.2% (treatment uptake for the standard was 88.3%). The mean time to treatment reduced from 19 to 4 days with 80% being treated within 7 days (compared with 48.5% previously). Future studies will look at POCT for NG/CT cost effectiveness.

 

MG remains a concern with increasing resistance to azithromycin and moxifloxacin. Associate Professor Catriona Bradshaw explained how Pristinamycin could not be considered an alternative treatment in those where azithromycin had already failed due to a disappointing cure rate of only 75%. However, Pristinamycin may have a role in special circumstances such as pregnancy as it is safe with few side effects.

 

Dr Elina Trembizki proposed PCR resistance testing could individualise NG treatment by accurately predicting ciprofloxacin susceptibility through TCC/ TTC wild type detection. It possible NG resistance to ciprofloxacin may by over represented through traditional culture methods though this should only be interpreted in an Australia context.

 

In the reproductive health lectures Mary Stewert highlighted the need for contraception education in men as although survey through a dating website revealed high rates of contraception use there was a lack of awareness of LARC’s and many believed hormonal contraception especially the ECP to be harmful which could negatively influence female partner decision.

 

Australia still lags behind in LARC with only a 3.2% uptake compared with 13.9% worldwide. Dr Amy Moten dispelled myths about IUDs explaining that PID rates are now <1-2% regardless of age and only in first 20 days post insertion after which time risks go back to baseline. Studies have even shown that there is no benefit of removing IUD in PID unless there is no improvement in clinical status after 48-72hours. Therefore PID should not be a barrier to IUD’s. Gabrielle Lodge looked at GP perspectives towards IUD insertion revealing barriers to include cost to train, minimal Medicare rebate and de-skilling due to small patient load.

 

There was a call to make MTOP de-centralised and so more accessible and affordable.  As despite misoprostol being available on PBS professor Angela Taft found many women find cost a significant barrier. Spontaneous discussion highlighted women’s experiences can vary widely depending on the state. Lauren Coelli described a successful nurse-led approach used in Victoria and emphasised importance in training all members of the MDT including receptionist staff to de-stigmatise.

 

Other interesting lectures included Dr Deborah Bateson speaking about POP (75mcg desogesterol  - not available in Australia) as a treatment for migraine possibly due to anovulation. Associate professor David Templeton who presented the increased follow up of victims of sexual assault due to improved relationship between sexual assault and sexual health services, councillors calling individuals to make appointment, separate waiting room, councillor obtaining sexual history, and personal phone call with negative results. >10% of these patients had an STI showing the importance and benefit of proactive follow up.  Todd Fernando discussed how the media/ literature fuelled view of aboriginal men either being heterosexual or hyper-sexualised MSM needs to be remedied to aid engagement with sexual health services and Tiffany Jones talked about how policy made LGBTIQ young people feel safe. Lack of policy and poor education in schools around LGBTIQT leads to increased bullying, days off school, self harm and suicide whereas promoting activism can me protective.  

 

 

Normal 0 false false false EN-GB JA X-NONE

 

Monday 14/11/16 – Day 1: Jan Edwards Trainee Session

Dr Danae Kent, Senior Registrar at Adelaide’s Clinic 275: ‘Testing for Rectal Chlamydia in Women – Is It Worth It?’

In short the answer was yes…and no! 

Rectal chlamydia infections in women have the potential to result in significant morbidity and enhanced HIV transmission. 

Few other Australian studies have looked at this topic.  The estimated rectal CT positivity rate in women is 5-27% (variable depending on population eg. higher in sex workers and sexually adventurous females).  Awareness of site of CT infection is important as this has implications for choice of treatment (rectal CT treated with Doxycycline vs genital CT treated with Azithromycin).

Method:

This South Australian retrospective study looked at women who received anal CT testing if they reported anal sex and/or anal symptoms.

Results:

Overall CT positivity rate = 8.5%

Young women less likely to have anal CT testing done but more likely to have positive anal CT result (of those with a CT positive result, 16% of women <20yrs were positive for anal CT)

Isolated rectal infections:

70% were found to have urogenital AND anal CT

19% were found to have rectal CT only

11% were found to have urogenital CT only

Therefore urogenital testing alone would miss 1 in every 5 cases of chlamydia confirming the value of testing for anal CT where a women reports anal sex and/or anal symptoms.  These findings are not generalizable to settings outside the sexual health clinic. 

Interesting food for thought and also a timely reminder of the importance of a thorough sexual history for the female client including enquiry about anal sex practices.

 

Bacterial vaginosis (BV) is a polymicrobial phenomenon that represents dybiosis or imbalance in the vaginal microflora. Gerald Murray today presented the findings of a cohort study that examined the relationship between the vaginal microbiome and BV.

298 women without BV underwent periodic assessment of their vaginal microbiota by 16s rRNA sequencing. Over two years of follow-up 51 women developed BV, giving an incidence of 9.75/100 woman-years. 

Certain taxa were associated with subsequent development of BV - a 1% increase in Gardnerella vagainalis conferred a 2% increase in BV. The poorly characterised, non-cultivable BBAV TM7 was associated with a 5-fold increase in BV, but Atopobium vaginae was not. 

Diversity of the vaginal flora was correlated with susceptibility to BV. Women with more diverse microbiome experienced greater fluctuations in flora between assessments, and these unstable microbiomes were more likely to develop BV. Interestingly, the acquisition of microbial changes associated with an increased BV susceptibility often preceded the development of clinically apparent BV by weeks or even months. 

Behavioural factors were also associated with the development of BV: a higher rate pf partner change and the acquisition of a new partner were associated with incident BV. This is consistent with the emerging view of BV as a sexually transmissible phenomenon. 

Then authors  hypothesise that BV is a sexually acquired instability in the vaginal microbiome that ultimately leads to a lack of resilience in a complex community. 

Posted by on in Social and behavioural research

Khadija Gbla is an inspirational woman who settled in Adelaide after attaining refuges status via the United Nations Refugee Program. In 2004 she became a peer educator in the Women’s Health State Wide program ‘Female Genital Mutilation’ (FGM) and is now the Director of 'No FGM Australia'.

Khadija raised an interesting point about the different values some cultures put on sexual health. For some CALD communities’ sexual health is not a priority as they have competing factors such as poverty or homelessness. Another interesting point made is clinicians need to consider women’s safety when discussing contraceptive options as partners may not be supportive of contraception and this could lead to violence.

 

Take home message:

Women should be asked about FGM and appropriate referrals can be made. Sexual health is a human right and we should support people to make informed decisions about their sexual health.

Khadija has an interesting Ted Talk available from https://www.ted.com/talks/khadija_gbla_my_mother_s_strange_definition_of_empowerment

Notes:

Family Planning Victoria have had a large push to help create resources to help youth engage and navigate sexual health services and education.

Through alliance with schools, medical teams, educators the moderation and creation of resources has been helpful in engaging youth.

Resources can be reviewed at rse.fpv.org.au

There is very little in the way of research into non heteronormative society in indigenous and TSI communities. Sadly the majority of portrayals are hyper sexualised and not representative of diverse gender queer indigenous community.

This is a need to understand that "gay health" is not exclusive to "sexual heath" there are many more areas of gay male health to be explored and engaged.

Many GLBTI youth are suffering significant prejudicial treatment within the schooling system. Schools without GLBTI policy have increased self harm, suicide, bullying and harassment of GLBTI youth. 

GLBTI policy has been shown to be protective creating increased safety as well as retention in the school system.

Many trans and intersex youth are leaving schooling rather than face the poor treatment while attending school. Trans and intersex youth are at higher risk of self harm, suicide, and bullying.

Many resources provided at schools are not inclusive and not helpful or supportive for GLBTI youth.

Current estimates are that 2 in every 30 students are GLBTI and without inclusion they can be lost to schooling, bullied, self harm and be at risk of attempted and completed suicide.

Notes:

HPV associate with 90% of anal cancers. HPV 16/18 is associated with 92% of the HPV related anal cancers.

Being an MSM associated with a 40x risk of HPV anal cancer. Being an MSM who is living with HIV shows an up to 100x risk of HPV related anal cancers. 

Spanc study showed that while a percentage of men with self clear of anal HPV infection this is less likely with HPV 16 infection.

Despite treatment guidelines not recommending HPV vaccination in men older than 26 the SPANC study showed that many older men have not been exposed to HPV 16. This opens the suggestion that vaccination with 9 strain HPV vaccine may offer benefit beyond the age of 26.

The indigenous population of Australia is suffering with disproportionate levels of STI's. Risk are 3x for Chlamydia, 18 x for Gonorrhoea, 4x for Syphilis. Barriers have been identified for men to get STI testing including lack of information as well as culturally appropriate male health workers to engage with clients for testing.

There has been a significant rise in Syphilis infections within Northern Australia's indigenous population. Rates are similar in men and women in the younger age group 15-29 years old. 

Given risk of congenital syphilis and intrauterine death a robust testing campaign has been initiated to test all women of child rearing age as well as intensive screening of pregnant women. 

Testing in pregnancy includes up to 5 tests during pregnancy and if a female has had a positive test she is then testing monthly till delivery and followed for 3 months post delivery to ensure no reinfections.

Notes:

Indigenous Australians have a disproportionally higher levels of Chlamydia and Gonorrhoea compared to non indigenous Australians.

Point of care testing for Chlamydia and Gonorrhoea in Remote North Australia has proven to be highly effective in ensuring rapid diagnosis and treatment of those infected.

POC testing has reduced time to treat from average of 19 days down to 72% less than 3 days and the majority treated in under 7 days.

Real time testing of Ciprofloxacin resistance in Gonorrhoea is emerging with testing for genetic patterns associated with Ciprofloxacin sensitivity as well as resistance.

Pristinamycin is a novel new antibiotic with dual action that may prove to be helpful in treating macrolide resistant Mycoplasma Genitalium. In doses of 2- 4 g daily it has shown 75% cure rate in previously failed treatment of MG. Pristinamycin has shown an acceptable side effect profile and safety in pregnancy when given unknowingly.

New PCR test kits are emerging that allow the detection of MG resistance detecting 5 different genetic markers. This may aid better directly therapies for treatment of MG.

Changes in vaginal microbiota have been associated with increased risk of bacterial vaginosis.

Risk factors include, reduced levels of lactobacillus, increased exposure to different vaginal flora via new sexual partners, high levels of Gardinerella as well as changes in stability and increased diversity of the vaginal flora.

Female partners of men diagnosed with pathogen negative non-gonococcal urethritis should be notified, tested and ?treated with review of partners data showing increased rates of symptoms in female partners (60%) and a 12% association with PID.

Gemma Sharp from the School of Psychology, Flinders University,S.A talked to us about the project she's involved in looking at Labiaplasty. I found this really interesting but results were pretty predictable.

She told us it's the most popular form of genital cosmetic surgery and Australia has seen a 3-fold increase from 2000-2014. It involves the reduction of the labia minora.

She was looking at the factors that motivate women to undergo labiaplasty and the psychological outcomes using two studies.

In study 1 (qualitative study) She interviewed 14 Australian women 5-16 months post surgery and identified five themes:

1 Media influence - comparing themselves with online genital images

2 Negative comments about genital appearance

3 Physical discomfort over aesthetic concerns

4 Satisfaction with surgery

5 Sexual wellbeing

86% of the women expressed concerns with labial appearance, large labia impacting their sex lives and feeling ashamed about how their labia looks.

After labiaplasty 71% of the women stated an improvement in self- consciousness, feeling more comfortable having sex and feeling more free. But 29% still had concerns after labiaplasty. 

She concluded that psychosexual counselling might be an option for these women.

In study 2 (quantitative study) she looked at the effects on intimate relationships and psychological well being, using 29 labiaplasty patients compared to 22 general gyne patients.

She found that overall the labiaplasty patients were satisfied >80% and only 35% reported complications (infections/severe discomfort) but there were no significant changes in relationship quality, sexual confidence, psychological distress, self-esteem or life satisfaction.

She concluded that although labiaplasty improves genital appearance, it has no effect on psychological factors and preoperative relationship status and psychological distress predict dissatisfaction with outcomes.

Again she thought it was important to think about psychological treatment.

 

Reproductive Health: Contraception, Access and Equity

 

Amy Moten from ShineSA dispelled some myths regarding intrauterine devices (IUDs) causing pelvic inflammatory disease (PID). Amy explained the reasons behind the poor uptake of IUDs in Australia in comparison to other countries.

The legacy of the Dalkon Shield has cast a shadow on the use of IUDs in Australia. The Dalkon Shield was an intrauterine device manufactured in the 1970’s. It became infamous for its serious design flaw-a porous, multifilament string upon which bacteria could travel into the uterus causing sepsis, miscarriage and in some cases death.  There are three intrauterine devices available in Australia- the progesterone IUD called Mirena and the non-hormonal IUD’s-copper T 380A and Multiload. IUDs are extremely effective long acting methods of contraception, which are under utilised in Australia. Only 3.2% of Australian women use IUDs V 35% of Vietnamese women.

Data from 12 randomised studies revealed that modern IUDs showed an overall rate of PID of 1.6 cases per 1,000 woman-years of use.

 There is strong evidence to indicate PID is related to the insertion process. 20 days post insertion the risk of having PID is the same as a non IUD user.

 Take home messages

·      There is no difference in outcome for women with PID who retained the IUD compared to those who had it removed

·      All women who are diagnosed with PID should be reviewed in 24-72 hours

·      IUDs can be used in nullips and there is no increased risk of complications in younger women

·      IUDs are a cost effective method of contraception and clinicians can help by dispelling myths regarding side effects

·      Contraception is very much a very personal choice. It is important that clinicians suggest appropriate contraceptive options for their patients/clients. Long active contraceptive options can be a great choice for women of all walks of life, especially those with chaotic lifestyles. I often suggest LARC for our ‘at risk’ young clients who are often homeless and using drugs.

      Angela Taft (La Trope University)-Medication abortion: access and equity following Mifepristone on the PBS

Medical termination of pregnancy (MTOP) has become more available Australia since restrictions were lifted on mifepristone. Mifepristone can be taken for 63 days/9 weeks after conception. Women can now choose their preferred method and the MTOP can be preferred over surgical interventions for many reasons. Taft explores access and equity in obtaining a termination, including reported challenges, preferred methods and out of pocket expense. The data was from Marie Stopes clinics from November 2014 to April 2015.

Demographics @ Marie Stopes clinics-

·      49% nulliparous but 35% had previous abortions

·      Over 83 % attended for TOP within the first trimester

·      Little difference in the cost of surgical terminations and medical terminations at  Marie Stopes clinics- non Medicare holders can pay up to $1160

·      Identified factors associated to late presentations include distance to clinic, not aware that MTOP was available, and financial difficulties

      Take home messages

Mifepristone is now available in Australia but there can be a significant cost involved which reduces access to lower income earners. 1 in 5 study participants expressed concerns about the cost of abortion and relied on the financial assistance of others. 

35% of clients attending for TOP have had previous abortions. It would be great if contraceptive advice and free LARC could be offered on the day women attend for terminations.  Angela Taft’s talk sparked some debate on why the price of medical termination of pregnancy (MTOP) was so expensive.

 KRC can offer free contraception to ‘at risk’ young people and other target populations. Free contraceptive options include the combined contraceptive pill, emergency contraception, implanon and mirena or copper IUD. Clinicians at KRC often refer clients for TOP and with the clients permission can liaise with the clinic and make a plan regarding contraception options post procedure.

 This session was followed on nicely by the amazing initiative of Lauren Coelli who established Clinic 35 in the Hume region. Her work has undoubtedly improved access for marginalised population groups.

 Increasing access to medical terminations of pregnancy through nurse-led models of care/Decentralising abortion services: The Integration of Medical Termination of pregnancy into a Rural Primary Health Care Setting-Lauren Coelli

Commenced MTOP in 2015

·      Accessible and equitable service-no Medicare required

·      Nurse-led model excellent opportunity to increase access to MTOP

·      Requires good working relationship with GP + Pharmacy who has undertaken MS2Step Training

·      Few GPs complete training as consultations associated with MTOP are lengthy (>45 mins) and there is suboptimal remuneration for GP.

·      The nurse’s role includes triage, pregnancy options, holistic assessment, investigations and referrals for ultrasound and specialist referrals.

·      The cost of MTOP at Clinic 35 costs between $0 and $38.20

·      In-depth planning process and ongoing communication is essential for the program to be successful

 Take home messages

This service is awesome. It is a step forward in the movement for sexual and reproductive empowerment of women in Australia and hopefully it can be emulated in other countries worldwide

 

 

 

 

 

Notes: 

Khadija Gbla's key note speech was fantastic. She has highlighted the importance of unpacking and going back to absolute basics when talking sexual health with people from culturally diverse backgrounds.

She has provided a timely reminder that we as Australian's are able to take many things for granted that others across the world, and those who have come to Australia may not have had access to.

It's important we "check out privilege" and stop to think were we are coming from as well as the recipient of the information we are hoping to share our message with.

 

Basil Donovan has well earned being the first recipient of the ASHA Distinguished Service Award. His work in sexual health with many of Australia and the world's best has changed the climate of sexual health in many profound ways.

 

Amber D'Souza gave a fantastic synopsis of the effects of the HPV virus in both men and women. She has highlighted the importance of vaccination for HPV and how prevention is an important tool against HPV given it's high impact on men who have sex with men in particular those living with HIV.

I was genuinely surprised to learn of heterosexual transmission of HPV, female to male, lead to marked rates of oropharyngeal cancers in heterosexual males.

Amber also gave a great preparation to later presentations on the relationship of HPV with anal cancers in MSM.

 

Finally a synopsis of new HPV screening, vaccination guidelines. Look out for 2 doses of 9 strain HPV vaccines in the near future.

Changes to cervical screening guidelines also highlighted.

Further details available at Future Changes To Cervical Screening Guidelines. 

 

Opening plenary was powerful  and a good example of the need for constant reflective practice:

with Khadija Gbla's ;

Discovering Sexual Health from a CALD perspective, addressing Sexual Health as a Human right, the need to reach out to all, LGTB et all, the need to be all inclusive

SexualHealth as a Western construct and the need to unpack that

Information is power!

The need to for currency of practice

Basil Donovan as ASHA Distinguished Service Awardee

Reflected on the past differing approaches by Family Planning,Sexual Health and organisations and how finally Service providers with ASHA are uniting  resources

Basil reflected on the need for the community to be more involved centrally

 the new shared  STI guidelines

the past work to decriminalise CSW

Looking back to the AIDs fear from 1983 

His early  Lancet articles and their timeliness

Indigenous Health review

Increasing POCT

ACCESS SURVEILLANCE :50 CLINICS Monitoring National trends and problem solving

The introduction and massive impact of the HPV vaccine: which carried through the days HPV presentations

The syhilis outbreak in Remote Australia

and the work needed ie chlamydia and less than 1/4 diagnosed

His message was TIMING is better than data

Again that strong message of ensuring reflective practice, and currency of practice

 

The plenary then aunched into all about HPV; oral to anal

Amber D' Souza; Rethinking HPV and Related Disease prevention

The changing epidemiology of HPV

Despite the HPV vaccination still greater than 5% of global cancers

Mindful that Australias HPV vaccination roll out and screening programme remarkable with 71% vaccinated zand acheived a herd immunity

UK 60.4%

USA 33.4%

Now evaluate to be able to continue in light of cost effectiveness 

Reseatch shows Number of vaccinations required for same HPV Ab response ;probably  2

What resource poor countries could use as rollout

The look at female and male vaccination in light of Public Health and cost effectiveness

Oral HPV 6x more common in males

Oral sex with females Increasing risk factor

.? HPV VL higher in cervical fluid than on penile shaft

Or reduced immunity

Males less likely to clear infections

But that sexual behaviour does not explain differnce re sex and HPV incidence

 

Marion Saville The National Cervical Screning Program; On the Cusp of Change,giving a VERY comprehensive overview on the new guidelines post the introduction of Gardasil in 2007

Giving caution of a global overview regarding discrepancy in surveillance between countries

Aust surveilance good

National Register for vaccination

High school coverage

GPs under notified older women

Still work to do in Indigenous and CALD communities as a continuing theme

Lowest 10% socio economic not getting to school

Safety of vaccine

Evidence of high levels Antibody response probably sufficient for life

Now vaccination offered to prevent secondary recurrence HPV

Looking at the 2 dose schedule

USA 9 valent vaccine approved

Hard to measure success, more adjuvent more pain

Probably will be the same in future for Aust re cost effective

Outstanding success cervical screening program

BUT Took 40 years from pap to be recognised as imporant scrreening tool

Frazer and HPV vaccination

But now need to address EQUITY

Modelling suggests 30% reduction cervical cancer on top of vaccination

Outlined new guidelines with new technologies

Self collection

Caveat no change to incidence adenocarcinoma only squamous cell Ca

Discussed quality improvement and COMPASS Trial

Carried through to afternoon session Clinical Sexual Health and Epidemiology:Anal HPV

And non clearance of Anal HPV in males esp HPV16 increased with age

No difference if HIV

2 HPV tests at least 6 months a part may identify male with persisting chronic HPV and the increased risk of Anal cancer

screening moving to HRHPV testing 

Ongoing research toward cost effectiveness and best practice and equity...

0 false 18 pt 18 pt 0 0 false false false

Day 4’s morning session was focused largely on PrEP, making it interesting and relevant to the Australian context.

 

Chloe Orkin (from the Royal London Hospital) began by providing a brief summary of the current situation and future prospects for PrEP.

 

She noted the current use (as PrEP) of standard antiretrovirals; the development of new compounds from existing classes (e.g. EFdA [NRTI]; dapivirine, MIV-170 and IQP-0528 [NNRTIs]; cabotegravir and MK-2048 [IIs]; and entry inhibitors [vivriviroc, 5P12-RANTES, PIE-12, nifviroc and trimer-D-peptide]); as well as new compounds from new classes (VRC01 and griffithsin [Neutralising antibodies]).

 

She also mentioned novel means of drug formulation that’re being developed: rings, inserts, suppositories, gels, films, soft implants, injections and douche/enema.

 

 

Sheena McCormack (University College London) presented an update on the evidence for PrEP effectiveness.

 

She began by presenting the a summary of currently available evidence as below, reminding us that overall (especially in MSM) PrEP is very effective; that adherence was a major factor in many of the studies where effectiveness was less good (particularly in young black MSM in the USA and in heterosexual populations).

 

She focused on the PROUD (continuous truvada as PrEP; immediately or deferred) study which looked at effectiveness, risk compensation and STI rates This study showed an effectiveness of 86% (90% CI 64-96%), with NNT = 13 (90% CI 9-23) – Dr McCormack commented that this compares favourably with other medications (such as statins) that’re approved for preventive measures. She also commented that some of those in the immediate intervention (PrEP) arm had significantly more unprotected anal intercourse than those in the deferred arm, and that rates of unprotected anal intercourse in both arms were relatively high. In that study, a rectal STI indicated a 1 in 6 risk of HIV infection in the following year.

 

Australia’s EPIC study was mentioned, particularly with regard to the fact that it targeted those at high risk of HIV.

 

She provided a summary of worldwide PrEP demonstration projects between 2011-2015:

-       32 projects in 16 countries

-       8478 participants with 7061 cumulative years exposure

-       Total HIV seroconversions n=67

à Highest rates in MSM 18-25 years (7.7/100 person-years)

à However available intracellular data showed undetectable or very low tenofovir levels in nearly all of those with seroconversion while on PrEP.

 

Episodic vs daily dosing – the importance of choice to effectiveness

HPTN 067/ADAPT study was mentioned: this study compared the use of daily, twice weekly (and another tablet after sex) and episode-driven PrEP in 3 populations (Harlem MSM/TGW; Bangkok MSM/TGW; Cape Town WSM). It showed that in the Bangkok population (who were generally better educated and suffered less social disadvantage) there was little difference in effectiveness between treatment arms, whereas adherence was much poorer for event-based PrEP in the other two arms (compared with continuous PrEP). This suggests that a choice of event-based or continuous PrEP may be useful depending on the population in question, and that if a population is likely to be adherent to episodic PrEP, this may produce cost-savings (less drug used overall).

 

 HIV infection despite PrEP

Those two cases of HIV being contracted despite good adherence (and adequate drug levels) were mentioned, including the “Toronto case” and the second case recently reported of a MSM acquiring a strain of resistant HIV. This reinforces the importance of reminding those on PrEP that it is not 100% effective.

 

Possible use of maraviroc as PrEP

HPTN 069/ACTG 5305 (Phase II Study of Maraviroc-Based Regimens for HIV PrEP in MSM) was discussed. In this study of n=406 MSM, people were randomised to oral maraviroc (MVC) only; MVC+FTC; MVC+TDF or TDF+FTC. 5 seroconversions occurred (4 in MVC-only arm), but in 4 of those plasma drug levels were low or undetectable.

 

Dapivirine-impregnated vaginal ring as PrEP

ASPIRE (n=2629; 27% risk reduction) and Ring (n=1959; 31% reduction) studies. Both in Africa.

However risk reduction was 60% in women >25 years of age; based on further data from the studies poor adherence was thought to be responsible for the poorer effectiveness in younger women.

Dr McCormack also mentioned the possibility of including contraceptive drugs in the PrEP vaginal ring to provide combined PrEP/contraceptive effect.

 

Conclusions

-       Overwhelming evidence of effectiveness of biological efficacy of TDF+/-FTC – which is not compromised by STI or risk compensation.

-       Population effectiveness not compromised by resistance (to date)

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-       Heterosexuals have a choice of drug; MSM have a choice of regimen; women will soon have a choice of delivery method.

 

Dr Deborah Konopnicki from Belgium gave a fantastic overview of the current research in prevention and treatment of HPV-related malignancies in HIV positive men and women on Day 3 of the Glasgow Congress.

 

HPV-associated infections and lesions are more frequent and their outcome is more severe in persons living with HIV.  The prevalence and incidence of precancerous lesions of the cervix/vulva/vagina are 6 times higher, and of the anal region are 15 times higher than in HIV negative people.  Recurrence of these lesions is also twice as frequent after treatment. Rates of cancer of the cervix are three times higher than in the general population, and rates of anal cancer are 40-100 times higher.  Mortality rates from HPV-associated cancers are high, particularly in the case of anal cancer.

 

Antiretroviral therapy against HIV decreases HPV-associated infections and lesions after several years of optimal viral control and immuno-restoration of high magnitude.

 

A new preventative vaccine that targets 9 different strains of high risk HPV was approved by the FDA in 2014/5 (Gardasil9).  The newer vaccine is associated with a greater reduction in rates of squamous intraepithelial lesions in women (79% reduction versus <30% reduction) and AIN in men (89% versus 62%) than the vaccines targeting genotypes 16 and 18 alone.

 

Due to its high cost, it has been suggested that perhaps one or two, rather than three, doses of the vaccine could be administered, but there is no evidence for the effectiveness of fewer than three doses of the vaccine in the HIV positive population.  It has unequivocally been proven that HPV vaccination is beneficial for both primary and secondary prevention of HPV-related lesions in this population, although guidelines vary regarding the upper limit of age at which they should beneficially be administered as primary prevention.

 

Recent changes in cervical screening in the general female population in high resource settings are also application to HIV positive women:  under the age of 30, HPV prevalence is too high to warrant the use of HRHPV screening; after 30, HPV testing has good negative predictive value for women with CD4>500, so future screening may potentially be conducted at lower frequency than current guidelines in this population. 

 

A new approach to cervical screening studied in limited resource settings in South Africa, Botswana and India over the past few years has been the “screen and treat” intervention.  This involves visual inspection of the cervix and high risk HPV screening – the results are available within two hours and high grade CIN can be treated on the same day with cryotherapy of trichloracetic acid.  This approach has been shown to significantly decrease the incidence of HGCIN and cervical cancer at 3 years.

 

Another interesting development in this area has been the use of topical Lopinavir to treat CIN.  A single-arm, proof-of-concept trial was conducted by Lynne Hampson et al in Kenya, in which vaginal self-application of Lopimune (Lopinavir/Ritonavir) gel was used to treat high grade CIN in 23 HIV-negative women.  The intervention was well-tolerated and systemic absorption was weak; cytological response at month 3 was 82%, with 64% resolution of the CIN and 18% regression to a lower grade.  The effect of the gel was thought to be due to Lopinavir’s local anti-proliferative effect on cells, and similar cervical concentrations would not be achieved with oral Lopinavir treatment.

 

There are limitations to anal cancer screening – although high resolution anoscopy is the gold standard it is costly and time-consuming, and so far no RCTs have shown a reduction in mortality from anal cancer with any screening program. Results from two RCTs on the use of anoscopy that are currently underway are due in 2018 and 2022.  Dr Konopnicki stated that her clinic in Belgium incorporates both cervical screening and anoscopy as part of routine care for HIV positive patients, however.

 

Finally, therapeutic vaccines made of the E6 or E7 oncogenes (genotype-specific) or their DNA to induce cellular immune response against E6 or E7 are in development, and in the future they could contribute to less aggressive ablative therapy for HPV associated lesions.

 

 

With just over two weeks until the virtual 2020 Joint Australasian HIV&AIDS and Sexual Health Conferences, now is a… https://t.co/qdLZhBZgQ7

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