Day three of the Australasian Sexual Health Conference 2016

Professor Alan McKee sparked an interesting debate today around sex education with his lecture ‘What we can learn from Pornography?...

Healthy sexual development is part of becoming a well-adjusted adult, right? …but what is 'healthy sexual development'? Is there such a thing and if there is, can it be taught and incorporate the beautifully diverse nature of sexuality and sexual identity?

Studies have shown that sex education can’t be left to families alone and calls for health and education to collaborate to improve sex education and incorporate themes such as pleasure as well as the well-trodden path of sexual risk – could it be possible that we might learn something from pornography in this regard?

 In Angela Davies’s lecture yesterday we learned that young people are already watching porn for a more detailed and pleasurable form of sex education. However, the overall impact of pornography is unclear. Some young people describe this experience as positively impactful in terms of preventing risk behaviour and normalising taboos and others report resulting harmful attitudes. The impact of pornography on body image can be positive or negative and In some cases young people report pornography had no impact at all.

Is there a role for picture books detailing the story and diversity of vulvas? flaccid penises? erect penises? Menstrual fluid? Ejaculation? so that young people get a sense that there really is no such thing as normal or perfect. 

One attendee pointed out that showing young people pictures of genitals in the context of sex education could contradict child protection programs where young people are taught that their genitals are private,  however, the overriding feeling was – pictures of genitals for sex education could be ok if in an appropriate and safe context.

Personally, I think we have a bigger battle - forgetting porn for a second, young people are constantly bombarded with expectations of whats 'normal' outside of school, Advertising prohibits any hint or curve of a labia. Are we to implicated in these built up expectations? After all how diverse are the drawings of genitals in our anatomy/ biology text books?

Maybe we can take example from the Netherlands  where young people having a later sexual debut, the vast majority use contraception the first time they have sex and describe there first experience as 'being ready'. These healthy and positive sexual experiences follow a  ‘comprehensive' sex education that starts at 4 years old and educates parents too.  In fact, ‘sex education’ is termed ‘sexuality education’ and incorporates young peoples rights and responsibilities leaving them more assertive and better communicators compared to there counterparts around the world.  

Take home messages

• Young people are curious about sex (and always have been)
• Some young people (regardless of gender identity) watch pornography which more often than not has an impact, and that impact is not necessarily negative.
• Sex education is incredibly important, especially around issues of body image, but needs to go beyond sexual risk to meet young peoples needs.

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Brent Allan spoke on the jading effect he feels, with the constant media reports of HIV "cures". He started by asking for a show on hands, to indicated how long it would be, before a cure would be available. The majority of the audience voted for 10-15 years.

He read several headlines from news report, published in the last week. These included "Cairns to trial HIV drug cure" which turned out to the trialling of PrEP. Unfortunately most of these headlines were from respected news agencies, which generates online discussion and the resulting analysis has a demoralising effect.

Brent also identified the need to provide hope for newly diagnosed HIV, even with these headline grabbing misinformation.

The session ended with an interesting question to the audience. If we expect a cure in 10-15 years, then what are we doing to help people living with HIV to transition to life without HIV? As positive as living without HIV sounds to me, for some who have lived with the virus for 20+years, they may lose their identify. 

Dr Cindy Liu from George  Washington University presented interesting findings on the vaginal microbiome today. 

 The term ‘dysbiosis’ refers to an ecological imbalance in the microbiome that impairs health. It moves away from the classic concept of infectious disease as being caused by a single pathogen, and moves toward the appreciation of disease as disruption to a complex, dynamic ecosystem. Disruptions might be the loss of ‘good’ bacteria, dominance of ‘bad bacteria’, but the imbalance leads to events that impair function, or induce inflammation. 

Earlier today, Liu described anaerobic penile dysbiosis: the polymicrobial colonisation of the subpreputial space with anaerobic flora, and its role in HIV acquisition. In her afternoon session, she built on this to describe one of the classic vaginal dysbioses: bacterial vaginosis (BV). BV is characterised by the overgrowth of anaerobic microflora, and reduction of Lactobacilli, and is therefore a vaginal anaerobic dysbiosis. BV is a common condition, and its management is characterised by persistence, recurrence. It is also associated with an increased risk of HIV acquisition, as well as a range of adverse pregnancy outcomes and pelvic inflammatory disease.

What is the relationship between these penile and vaginal anaerobic dysbioses? Are these phenomena sexually transmissible? The anaerobic organisms implicated in both processes certainly have considerable overlap, and evidence from several quarters supports the sexual transmission of BV.

 Liu and her colleagues enrolled 165 uncircumcised HIV-negative Ugandan men and their female partners into the Rakai Health Sciences Cohort. Self-obtained vaginal swabs from female partners were assessed for BV using the Nugent score, while swabs from the coronal sulcus were collected from men for assessment of their microbiome using 16S rRNA amplification.

Penile microbiomes were found to fit into four distinct patterns, termed Community State Types, which ranged from microbiomes with low diversity and few anaerobes (CST 1-3) to communities with very high diversity and a rich population anaerobic flora (CST 4-7): so called anaerobic dysbiosis.  

 Bacterial vaginosis was found more frequently among female partners of men with anaerobic dysbiosis than in men with lower levels of diversity and less anaerobic flora. This supports the hypothesis that anaerobic penile and vaginal dysbiosis are sexually transmissible and results from sharing of anaerobes within heterosexual settings.

 Longitudinal studies are needed to prospectively observe transmission events between couples, as well as account for potential confounders such as hormonal factors, hygiene practices and so on. Higher resolution molecular identification tools to better describe phylogenetic relationships between organisms shared by the partners are needed to confirm transmissibility.  

I haven't come across PrEP before - it is not easily accessible in Western Australia, although a few patients have obtained it through personal importation.  Hence, the sessions on PrEP were of particular importance to me as I'm sure they will be filtering through to WA very soon.  In particular I enjoyed the summary by Prof Jared Baeten, and I've tried to summarise my learning points below.  I've combined two of his talks into one.

Firstly, I love this quote that he put up (forgotten who said it though): all truth goes through three phases: it is ridiculed, violently opposed, and then accepted as self-evident.

• PrEP works: those who had tenofovir in their system had a >90% reduction in HIV transmission
• PrEP works for high risk patients
• a single agent may work as well as dual agents (e.g. TDF only = 85%, TDF/FTC = 93%)
• adherers adhere
• not everyone used PrEP, but those who did use it tended to be consistent users
• non-adherers rarely started adhering
• there wasn't much change in behaviour after 1 month
• surprisingly, real world effectiveness was better than efficacy in the studies
• ?adherence was better in real life than in the trials
• PrEP  has several additional benefits
• decreased anxiety
• increased communication and trust
• increased sexual pleasure and intimacy
• chance of developing eGRF <70 while on PrEP if your baseline is >90 is extremely small
• rising STI rates in the US have been happening for a while, even before the introduction of PrEP
• PrEP works even when STIs are present

Most of the informal feedback I've heard before today has been that PrEP is associated with an increase in STIs but if the data above is applicable to Australia, then perhaps that isn't quite true.  I think the evidence if favour of PrEP is mounting, and the major obstacle in Australia is probably the cost-benefit ratio...

"Holding Space for those who hold doubts" by Christy Newman, was very interesting. It described a view from a patient's perspective of what it means being on long term treatment possibly for rest of their lives and the implications.

There are several reason as to why patients may not choose to be on treatment. Some being just not ready for a life time commitment, some dealing with the new diagnosis, financial situations, co-morbidities that they already have which may affect or delay them from starting ARVs or simply being on long term medications.

It was clearly outlined with examples that patients need to have an option of being able to make choices in regards to when and whether they want to be on treatment. Are they on treatment as they need to be on it for their own benefit or is it to protect others from acquiring? Sometimes the side effects or the disruption caused by taking these medications would raise the question in their mind " protecting others from acquiring HIV? not a good enough reason to start meds"..... A point to be noted.

As clinicians it is our responsibility to explain the individual benefit of ARVs and the Public health benefit to the patients. However it is the individuals choice as to which direction they want to take. Hence holding space for those who hold doubts is an important step in HIV care.

This session of the Sexual Health Conference was musical and entertaining, starting with the music video of "Lady Sings it Better". It was played, to introduce the audience to the website:

www.iloveclaude.com  (this website is 18+, so check your kids are out of the room)

The target audience are Kink, BDSM, LBQ and sexually adventurous women, who have a high incidence of STI's and often feel culturally excluded from safe sex and health information/services. 

The website uses art projects (some sexually explicit) to entice woman to the website, then they can navigate to identify resources, events, testing, Q&A, health services and party packs (the last is posted to the persons house).

In the last 8 months, they have had an increase of 300% in traffic to the site.

The take home message

Woman who identify as not heterosexual have a higher incidence of STI's and risk behaviour, due a lack of targeted services, information and testing. As this demographic don't identify with the images and language currently used in woman's health services.

I see a need for an urgent rethink on how to engage this communitys needs for services/education/testing.

Satellite Session:

Fantastic expert  panel presentation informally discussing reality of target and inviting audience participation

Consensus a Challenging target

Possible to eliminate as Public Health threat if role out of new treatment continues

Treat as prevention to decrease new infections

Do need vaccine as resistence possible

Possibly Realistic target have the tools, systems, funding

Need to ENGAGE people

Large population of HCV , it is not their priority

greater 40,000 treated  by end year but  many still not aware treatment availability, also ageing population

Need GP's to take up treatment

need to test, need good history taking ,use database

Remember STIGMA prevents accessing GP

need to increase training for GP's in Hep C and treatment

Open treatment landscape

Move out of Hospital specialist, GP could  use if not got skill set

Target will need massive investment for Aboriginal Medical Services

15-24 ages :Indigenous 8x higher Hep C rates

Increasing IVDU under acknowledged

And Prison

Will need sysrems to monitor who is on treatment

think treatment as prevention, frame positively, can cure

Solid plan to include Primary care, main contact point for Indigenous population

HIV coinfected treat early,  care re reinfection but Caution STIGMA

Remember DDI, be aware

HCV and HIV VL not an issue

BUT noted easy for the experts to say  need to role out updated info and guidelines for GPs

Reinfection main risk Prisons

Discussion around barriers to OCT (opiod substitute therapy/methadone)

Difficult to access in prisons....THE DIFFICULT area despite funding

NEED SAFE INJECTING PRACTICES and regulated needle exchange

30% Indigenous in prisons including youth

SA making inroads re strategy

Reminder Indigenous mobility 

Suggests Research grant re what it would take to get to target in Indigenous population

Cairns area low IVDU BUT caution change

Prison Mareeba attitude to treat prompt and often

Remember to look GLOBAL

Reminder of costs and increasing problem crystal meth

Problem HePC treatment still mainly metropolitan area

Need strong GP networks

Resistence in initial HCV regimes not a problem if Fail may need 2nd line

Need traditional Public Health approach

Indigenous population need treatment as prevention and to hear benefit of cure

Discusion re HIV group take on HCV as experienced

Need to be realistic, limited specialists,liver clinics problematic

Use of NPs

Need to be able to write prescriptions....in the pipeline

Overall consensus came at role out was backwards

Ivory Tower Not as Public Health problem

Approach should have been: 

ASSUME population dont know

Hep C much more prevalent

GET tested

Treatment can cure

Access to clean needles

Implement systemic changes in Primary care

Who are pos

Who is on treatment,adherence

Chronic care plans......

Overall great opportunity to see where the new treatment role out is at with a target date set for HCV elimination...

and opinions at what needs to be done 

Highlighted the continuing shame to ignore Indigenous population requirements, 

We once promoted safe injecting,needle exchange....

The title Australia leads the world is not deserved until it is truly inclusive to its Indigenous population needs

This was a sponsored satellite symposium, held at the ASHM/Sexual Health conference. It consisted of a panel discussion which was chaired by Dr Norman Swan.

The question posted was- Can Australia be Hep C free by 2026? The short answer is....possibly.

Back ground

Hep C eradication treatment started this year. 20,000 people have been treated and by the end of this year 45,000. The bulk are patients were keen for treatment. Currently 82% of people with Chronic Hep C in Australia, have been diagnosed. This leaves 22% diagnosed. There is a dis-proportionally higher prevalence in the indigenous and incarcerated populations.

Resistance to treatment

Concerns remain in co-infected patients, that eradication treatment is difficult or may impact their HIV.These concerns linger from previous Hep C eradication treatments. They don't translate to the new treatment.

There are some drug interactions between ART and Hep C eradication treatment, however these can be managed.

Attitude change

An attitude change in government, patients and health care providers is required, to identify the remaining 22% of undiagnosed patients. This is needed, as without a significant reduction in Hep C in the general population, reinfection may occur. Re-treatment will then be required, and should be offered.

Hep C resistance

This has already occurred and needs to be avoided. Ways to prevent resistance is discussing with the patient to determine if they can access and afford the medication, for the entire treatment course. A wavering of the cost of opioid replacement therapy, needle exchange in prisons, nurse practitioner to subscribe treatment and patient education on preventing reinfection, will also contribute to preventing resistance.

Take home message

The uptake of Hep C treatment has been fantastic. Limit the opportunity for resistance by reducing the opportunity for partial treatment. Educating patients on preventing re-infection. Identifying patients who may have Hep C but never tested.

If this treatment to work, then we (and the government) needs to approach this treatment, like the Small Pox Eradication Program.

 Cindy Liu from the Milken Institute School of Public Health, George Washington University presented her findings on the relationship between the penile microbiome and HIV susceptibility. Liu hypothesized that the penile microbiome drives pro-inflammatory responses and in turn increases HIV acquisition.

 The space underneath the foreskin is a unique environment with a characteristic microbiome. Analysing subpreputial swabs from men in Uganda, Liu and her colleagues used molecular techniques to investigate bacterial populations prior to and after male circumcision. 16S rRNA sequencing was employed to characterise bacteria to genus level, and a pan-bacterial DNA RT-PCR was used to quantify total bacterial load. Together, these were used to estimate the absolute abundance of specific bacterial taxa in the subpreputial space.

Prior to circumcision, the subpreputial space was characterised by a diverse bacterial community that varied between individuals and over timel. A wide variety of anaerobes, including Prevotella, Finegoldia, Peptoniphilius, and Aerococcus, were isolated in high numbers. Post-circumcision, the populations of these anaerobes reduced, and resembled flora from other skin. Anaerobes decreased, populations became less variable, and Lactobacilli increased.

 Expanding on this, the investigators examined the immunological responses to these changes in the microbiome. Langerhan cells, the antigen-presenting cells par excellence of mucosal surfaces, are thought to be integral to HIV acquisition. In the inactivated resting state, Langerhan cells ingest HIV virions, and lyse them prior to presenting the lysed products to lymphocytes at the lymph node. In activated Langerhan cells however, degradation of HIV virions is bypassed, resulting in presentation of intact virus to nodal lymphocytes and the commencement of viral replication. Anaerobic flora were postulated to be triggers for Langerhan cell activation.

  Liu found that IL-8, one of the key cytokines implicated in immune activation, was significantly higher among men colonised by Prevotella, and other key anaerobic organisms.  IL-8 is known to attract neutrophils along a chemotactic gradient, and induce them to release MIP 3a alpha and MCP-1, which in turn lead to recruitment and activation of CD4+ T lymphocytes, drawing them closer to the epithelial surface.

 This work supports the hypothesis that an anaerobic subpreputial microbiome induces pro-inflammatory local immune responses, and that these changes are negated by male circumcision.

 Further work on the correlation between the penile microbiome and HIV acquisition is keenly awaited. Liu’s current collaboration with the Kirby Institute will examine the role of the ‘dorsal slit’ modified circumcision commonly practiced in parts of PNG, and will hopefully give insight into this cultural practice’s potential role in HIV prevention.

Amber D'Souza outlined the epidemiology of anal cancer pointing out the significantly elevated risks for HIV positive MSM. She found DARE acceptable to patients within a study of 327 men.

Dr Jason Ong posed the question "What should we be doing with our patients now?"

He gave compelling reasons to screen for anal cancer targetting the most at risk, that is HIV positive men > age 50 ideally with an annual digital rectal exam to try and detect anal cancer at an earlier stage than is currently achieved with reactive checks related to symptoms.

50% of anal cancers are visible externally ie just looking would make a huge difference and currently less than 10% of HIV positive MSM have annual anal exams.80-100% will be found with DARE.

It is a simple safe cost effective and acceptable practice and can lead to better outcomes.

The evidence for screening for precursor lesions seems less compelling. 

HSIL is present in 30-50% of HIV positive gay men however only 1/400 progress to cancer in HIV positive men and 1/4000 progress to cancer in HIV negative men. 

SPANC has greatly increased understanding of this process.?Highest risk to progression to anal cancer is seen in those with persisting HPV16.

It was also suggested by Jason and Dr David Templeton to consider HPV vaccination in this group as despite the lack of evidence for efficacy, it may work.

From positivelife NSW we learned that most PLHIV  thought their risk for anal cancer was the same or lower than the general population.

84% of respondants in that survey and 64% HIV respondants had never talked to thier doctor about anal HPV/cancer- we should clearly be doing better than this.

Epidemiology of Anal HPV and Anal Cancer

Overview of the role of HPV in cancer.

Over 100 different types.

HPV 16 causes over half anal cancers. Other oncogenic types together cause about 80% of anal cancers.

Infection with many types is common.

Over 40% MSM have HPV infection at any one time. More common in HIV positive, and more common again if immunosuppressed which makes clearance less likely.

Anal cancer increases with age above 45 years.

The rates are much higher in HIV positive MSM compared with HIV positive men.

In the current HAART era 3% of HIV positive MSM develop anal cancer, rates that equal cancers like colorectal carcinoma.

Screening was offered and readily accepted.

In HIV positive individuals there was almost twice the number of abnormal PAPs compared to HIV negative.

Abnormal cytology had high sensitivity but low specificity.

Adding HPV 16 + increases specificity.

What should we be doing for our patients now?

The HPV vaccines are a game changer.

Should we screen for early HGAIN (high-grade anal intraepithelial neoplasia)?

Similarities with cervical carcinoma, and that has a screening program.

There are key differences - larger area to swab, harder to identify lesions, different natural history (more high grade lesions less likely to progress to cancer), 40-60% would need to go on to high-resolution anoscopies, we need better treatments for high grade lesions.

Currently, more than 50% of anal cancers are visible externally, with an average size of 2.9cm, making them at least stage II disease.

Are we ready to screen for early cancers?

Can we implement early detection with an annual digital rectal exam?

Most HIV physicians think it is very important to screen for anal cancer, yet hardly any do.

Annual DARE (digital anal rectal examination) is well tolerated and an acceptable screening test for patients.

An update of the Study for the Prevention of Anal Cancer (SPANC)

High grade lesions are 5 times less likely to progress to cancer than cervical cancer in HIV positive men and 50 times less likely to progress to cancer in HIV negative men.

Mean age was 50 years.

Mean duration of HIV infection 15 years.

90% on treatment.

Almost all had CD4 nadir < 200.

Almost all were virologically suppressed.

After 1 year of SPANC the following findings:

The rates of HPV 16 were very high.

Clearance of this type is less than half of the other types.

Lesions were not associated with age or length of time infected with HIV.

High grade lesions were related to immunosuppression and lifetime anal experience.

New infection is common.

There is a high rate of 9-valent types in infections.

Over 50% of lesions persisted for 12 months.

Anal cancer is a huge and increasing problem.

Educating the community about HPV and anal cancer

AFAO (Australian Federation of AIDS Organisations).

The Bottom Line - campaign developed by AFAO to increase awareness of HPV and anal cancer.

Increasing awareness of HPV infection, DARE, anoscopy and biopsy, and information for those diagnosed with anal cancer.

Campaign materials included a web-site (www.thebottomline.org.au), 2 printed booklets for clinicians to give to their patients, poster.

A community perspective on anal cancer and anal HPV

Postal survey of how much respondents knew about anal cancer.

People thought their risk of anal cancer was the same as the general population.

People did understand what the symptoms would be.

Most had never discussed HPV or anal cancer with their doctor.

Of those that did discuss this with their doctor, it was the patient that brought it up.

One third of people would be really uncomfortable discussing this with their doctor.

76% had never been screened for anal cancer.

Most common examination was DARE, followed by high-resolution anoscopy.

84% hadn’t been vaccinated.

Living through the diagnosis and treatment of anal cancer

I was diagnosed with anal cancer in 2014, aged 52.

Diagnosed with HIV 1999, started ARVs 2005.

Having annual DARE because of family history of prostatic carcinoma.

Had surgery, then went back to work the following week.

Started chemoradiotherapy.

Looked after himself mainly, despite not coping well.

I needed to return early for a chemotherapy session, my liver was not functioning properly.

My skin was prickly, I was feeling nauseous, and it was recommended I admit myself to hospital.

Was told liver wasn’t working and I had to stop my HIV medication and pain relief.

I was released from hospital after 8 days, and prescribed bactrim, and had lost 20kg.

My CD4 count had dropped to 70.

I began my HIV medications again, and regained weight, but my kidneys shut down.

I had a problem with an overactive bladder throughout this (it was unclear what the cause was, my prostate or post-radiotherapy change). I was catheterised with a long-term catheter a few times, and developed a UTI.

My cancer has been cured.

My bladder has improved.

Questions

Is there a benefit vaccinating older people with early anal lesions?

There is evidence that early cervical lesions do have reduced recurrence following vaccination but no evidence yet for anal.

It is only funded for under 25 year olds, but if you can afford it, it is unlikely to do you any harm.

Should we be doing a DARE on HIV negative patients?

No, it is not cost effective, because it is not common enough.

If you’re going to do it, do it on a regular basis.

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

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

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

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

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

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

Perhaps the key messages are:

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

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

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

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

Well I didn't think I'd be blogging on the penile microbiome, but Cindy Liu, Assistant Research Prof from George Washington Milken Institute School of Public Health gave such a fascinating talk on the role of the penile microbiome in relation to circumcision on acquisition of HIV that I wanted to at least highlight this research. It is of interest to my role as CNC of Victorian NPEP Service given that circumcision is taken into account when assessing HIV risk for men having insertive intercourse.. My understanding of why circumcision is protective has just increased. 

Firstly, microbiome throughout the body is being increasingly recognised in playing a role in certain diseases.

Circumcision is known to be protective against HIV acquisition for the following reasons:

1. Decrease in at-risk surface area i.e. epithelial lining of foreskin

2. Increase of keratinisation 

3. Change in the sub-preputial micro-environment 

4. Change in penile microbiome

The study involved taking a swab from the coronal sulcus at baseline and 12 months in 2 groups of men - those who were circumcised and those who were uncircumcised.

There was an increase in both the type and density of anaerobic bacteria in uncircumcised men, and a small increase in skin associated "good" bacteria. The anaerobic bacteria found were pro-inflammatory, therefore attracting cytokines to the area, activating HIV target cells, such as Langerhans cells and increasing risk of HIV acquisition.

That is it in a nutshell and I am looking forward to Cindy's next talk this afternoon on BV, a condition we know is characterised by proliferation of anaerobes, and HIV acquisition

M. genitalium was isolated 30 years ago.

The organism is difficult to culture, and NAAT is difficult to access.

Commercial NAAT point of care testing is around the corner, so diagnosis is about to become much more accessible.

It has taken longer to establish its role as a pathogen because it is more commonly asymptomatic.

No evidence to support screening, just test those who are symptomatic.

Prevalence is about 1-3% of men and women.

Has similar clinical features to chlamydia.

Increases the risk of tubal abort and PID 2-fold.

No cell wall so not sensitive to penicillin-like antibiotics.

There has been widespread use of azithromycin for NSU symptoms, so macrolide (azithromycin) resistance increasing and is now at 50%, however it remains the first-line recommendation.

Moxifloxacin looked promising but resistance to this is now at 15-25% and increasing, currently for second-line treatment.

Guidelines concentrate on urogenital infection and don’t cover rectal infection.

Pristinamycin currently is our only other option, reserved for third-line treatment.

Worldwide we are seeing increasing notifications for syphilis and gonorrhoea.

This is despite effective treatments for both, with the caveat that resistance is emerging for gonorrhoea.

Why is this happening? Various theories.

What can we do about it? Infectivity, number of susceptible contacts, duration of infectivity.

Infectivity - use of condoms with oral sex? Little else we can do to influence this.

Number of susceptible contacts (the rate of change of sexual partners) - vaccinations, chemoprophylaxis (doxycycline)? Again, little else we can do to affect this.

Duration of infectivity - early detection and treatment (sexual history, is your practice gay friendly, doing the right test, point of care testing), strengthening partner notification? Yes, these are within our ability to affect change.

Most STIs are diagnosed in primary care.

Testing rates in primary care are low.

90% of Australians visit their GP annually.

We have the opportunity to affect change.

Hepatitis C was first discovered in 1989.

Overall worldwide prevalence of 2.8%.

Most infections are acquired parenterally, with a significant amount of vertical transmission.

A large well powered study showed a very low sexual transmission rate among heterosexual monogamous relationships (0-0.6%/year, condoms not required but should be advised that they will reduce the risk).

What about MSM?

Hepatitis C incidence in HIV positive MSM has increased exponentially.

Risk factors are intravenous drug use, condomless anal sex independant of intravenous drug use, and syphilis infection independent of intravenous drug use.

There is also sexual transmission of hepatitis C in HIV negative MSM related to chemsex who are on PrEP.

More likely with rough sex and fisting.

Reinfection rates are common.

Screening is recommended annually in HIV positive individuals.

In HIV negative individuals we probably don’t need to screen for hepatitis C routinely, but should consider it in people on PrEP.

Most studies from United States.

Traditional patient referral - patient tells partner go to the doctor, you may have an STI.

Assisted patient referral - patient uses some aid e.g. fact sheet, online notification websites.

Patient Delivered Partner Therapy (PDPT) - strong evidence that this was better than traditional patient referral, but no better than other assisted patient referral.

Considered safe - no episodes of anaphylaxis or major events.

Decreased the incidence of chlamydia and gonorrhoea in a US state by about 10%.

Some studies gave the medication, others provided a prescription for it to the pharmacist.

The prescription was taken up as readily as the direct supply of medication in studies.

Fewer than half of pharmacists knew PDPT was legal. Pharmacists may need training.

In Australia it was thought that PDPT could be used to obtain medication to disguise child abuse.

Consultations are underway to use a phone number on a prescription rather than the traditional patient address to facilitate PDPT prescriptions in some states.

How do we get this into primary care and get GPs to adopt it?

Rectal chlamydia is the most common STI in MSM.

Rectal chlamydia is more common than urethral.

Observational studies suggest doxycycline is more effective than azithromycin, but there is no evidence from RCTs

There is a move away from azithromycin to doxycycline.

There is much less evidence for mycoplasma genitalium.

M. genitalium was much more common in HIV positive men than HIV negative, accounting for 21% of symptomatic proctitis (as common as chlamydia) compared with 8% symptomatic proctitis in HIV negative MSM.

May be present in 4% asymptomatic MSM rectally.

M. genitalium is present in MSM and may be increasing.

Most are macrolide resistant.

Recommendations exist for urogenital infections, recommending azithromycin first-line, and moxifloxacin as second-line.

Until we have more evidence on how to treat rectal infections we will need to follow the recommendations for urogenital infection.

Third-line treatment is with pristinamycin.

There is a problem using monotherapy in these situations and we are likely to see resistance emerging.

Unfortunately synergy of pristinamycin with other antibiotics hasn’t been good.

Success rates using pristinamycin are about 85%.

Why is gonorrhoea so common in MSM when chlamydia and warts are not?

There must be something different in the way it is transmitted.

Sex without kissing increases with age.

Kissing only partners is much more common in gay men compared with heterosexual men.

Gay men may have many kissing partners in a club in a night.

Because urethral gonorrhoea becomes symptomatic quickly it gets treated, meaning at any point in time, the prevalence of gonorrhoea in the gay community is urethral in < 1%, rectal in 9% MSM and pharyngeal in 11%.

This translates into incidence rates of 3% urethral, 9% rectal and 44% pharyngeal.

Kissing and oral sex is important. The penis is irrelevant. It is just a poor bystander!

One of the things that the HIV/AIDS pandemic did was to bring sexuality and sexual health medicine into the fold.

Sexual behaviour is complex.

Disciplines from the laboratory services to the epidemiologist, psychologist, social worker or nurse.

There is a vast array of environmental factors that contribute to behaviour and risk taking that a multidisciplinary approach is well suited to untangle.

Evaluation of one-stop-shop models of sexual health service provision.

One-stop-shops offer the most efficient way to provide sexual health services.

We are good at collecting data on soft outcomes, like are patients happy with the service, were they treated with respect, was their confidentiality preserved, etc.

We are not good at collecting evidence on hard outcomes like reduction in teenage pregnancies, STI rates, or behaviour change etc.

MSM still prefer the GUM model of provision.

Heterosexual men prefer the one-stop-shop model because they feel that family-planning services are for women only, and they are distrusting of the confidentiality offered by General Practitioners.

Integrating services in one-stop-shops, e.g. HIV services introduced stigma and deterred women from attending.

Staff at one-stop-shops was mixed, with some staff feeling excited that they offer a good service, and others feeling there was less opportunity to specialise.

Are some services better off set apart from integrated sexual health services?

Integrating alcohol interventions into sexual health care.

There is a plethora of evidence to suggest that alcohol is probably the main predictor of unprotected sex and numbers of sexual partners.

Brief interventions has not demonstrated any significant reduction in alcohol consumed or sexual risk rates after 6 months suggesting this is not a cost effective approach.

Substance misuse and sex - chemsex.

Prolonged periods of often unprotected sexual activity, with multiple partners and multiple drugs.

A small number of studies show fairly intensive behaviour modification interventions can reduce chemsex behaviour.

PrEP is now another option.

Can we integrate these services into the one-stop-shop model or should we be referring off to more specialised services.

There is a strong rationale for school based sexual health clinics.

Takes services closer to one of our key service user groups.

There is little evidence whether they work or not.

There is some evidence of reduction of teenage pregnancy and chlamydia rates but the fact is it has not been looked at well.

In fact, there is little evidence that sex education reduces pregnancy or STI rates.

Abstinence only interventions were found to be completely ineffective.