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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Take home messages on the importance of the genital mucosa in transmission and pathogenesis

 

Beginning with a plenary presentation on day one of the Australasian HIV&AIDS conference the complexity and importance of understanding the relationship between STIs and HIV was laid bare.

Associate professor Jo-Ann Passmore, from the University of Cape Town gave a fantastic presentation with a few key messages. She was presenting data on the vaginal mucosa of South African women prior to acquisition of HIV infection and the role of STIs:

  • A healthy female genital mucosa is already an effective barrier to pathogens.
  • Inflammation in the genitals exacerbates the likelihood of HIV establishing an infection as the cytokines draw in the very cells HIV needs to infect.
  • The inflammation seen in the genitals is different compared to inflammation markers in the plasma.
  • STIs are a driver of inflammation.
  • There is heterogeneity between the various STI and inflammation (cytokine profiles) they induce.
  •  Chlamydia, the most prevalent STI is very inflammatory.
  • Using the inflammation markers, the researchers could identify 70% of HIV seroconverters.

 

Delving further into the proteins and associated inflammatory markers, Lyle Mckinnon presented data from the CAPRISA004 trial (Centre for the AIDS Programme of Research in South Africa), in Durban, South Africa which aimed to elucidate the mechanisms behind genital inflammation increasing HIV acquisition risk. They looked at the soluble mucosal proteome and associated cytokine expression in female Kenyan sex workers. Out of around 500 proteins measured, they found 3 that are involved in cell migration and 7 that decreased mucosal barrier function. These 10 proteins were the defining feature of women with elevated inflammatory cytokines and allowed them to predict which women had the highest inflammation.

Rather than being a helpful way to repair tissue and fight pathogens genital inflammation in this situation may be reducing the effective barrier of a healthy genital mucosa and increasing the risk of acquiring HIV. Genital inflammation may help to explain high rates of HIV transmission when the per –act transmission risk (1/1250 for vaginal intercourse) is low.

 

Next, Keith Fowke from the University of Manitoba gave a presentation on an innovative approach to reduce risk of HIV transmission – using low dose anti-inflammatory drugs.  

Keith set the scene by explaining that younger women have the highest risk of acquiring HIV based on their inflammation patterns and this may peak shortly after sexual debut or in the earlier years of sexual activity. Likewise, STIs are known to also be more inflammatory in younger people made worse by younger people having the highest rates!

In reference to female sex workers specifically; inflammation levels seem to decrease over time and markers of inflammation can increase from as little as a one month break from sex work. This suggests a model of mucosal tolerance over time with a peak risk of acquisition in between the stages of transactional sex and first identifying as a sex worker, arguably when these women are most at risk of acquiring HIV based on non-biological factors.

Taking this forward and with the acknowledgment that activated CD4+ T cells (caused by inflammation) are 1000x more susceptible to HIV infection than non activated cells it seems pertinent to consider modulating the inflammatory response as a prevention strategy.

The researchers identified 80 low risk women from Kenya and established baseline activation levels, then randomized them to take 6 weeks oral dose of either Aspirin (aka acetylsalicylic acid or ASA) or hydroxychloroquine (HCQ) which is used in the treatment of rheumatoid arthritis. They found a significant reduction in the percentage of CD4+ CCR5+ T cells in both PBMCS and cervical mononuclear cells (CMCs) for those taking aspirin and saw a similar reduction in CD4+ CCR5+ T cells in CMCs for those taking HCQ.

Besides the take home message that it works…..and aspirin in particular is already taken by many people around the world, the participants reported that taking the drugs were non-stigmatising, something which could have positive effects for adherence which in turn increases the efficacy of the prevention strategy.

 

Moving from one side of the perineum to the other, Andrew Harman from the Westmead Millennium Institute gave an informative and visually intriguing (pictures below) presentation on interventions at the mucosa or research working towards that end.

He outlined the research by first explaining about the large amount of heterogeneity between and within the immune cell subsets of the genital and anal tissues (dendritic cells in particular). Dendritic cells are of interest because of the role they play in transferring HIV from the epithelium to CD4 T cells.

Shockingly and relevant to the Australian epidemic concentrated amongst MSM, very little is known about the role  dendritic cells play in transferring HIV to CD4 T cells in the tissues of the colon and anus. This is in comparison to the female genital tract where the role of dendritic cells is much more understood.

The main reasons for this are that healthy human tissue is difficult to obtain, (especially anogenital tissues!) dendritic cells are hard to isolate and dissociate and even if they can be isolated, they are in small numbers.

So, over many years Andrew has had to establish collaborations with plastic surgeons, colorectal surgeons, urologists and gynaecologists to gain access to the full range of anogenital tissues – see image below for process of preparing human tissue. This has led to profiling of the various immune cell subsets in anogential tissues and in particular a novel population of rectal dendritic cells that can be identified by the combination of cell surface receptors proteins. If this can be characterised further it could lead to the translational goal of producing compounds that block these cell surface receptors, therefore preventing these cells playing a role in transferring HIV to CD4 T cells. Ideally a compound of this nature could be applied as a tissue type specific microbicide in the future – watch this space.

b2ap3_thumbnail_skin.JPG

 

 

HIV and Migration: All is NOT fair in Love and War

Slightly belated report back from Friday morning's session.

President of AFAO, Dr Bridget Haire opened this session - in the absence of Dr John-Paul Sanggaran, the former Medical Officer, Christmas Island, Queensland. Bridget read extracts from a moving letter Dr John penned to highlight to governing bodies the multiple inadequacies in health management of HIV testing and treatment on Christmas island.

In it he pointed out that often an HIV test result takes at least 1-2 weeks due to logistical factors, by which time the patient has usually been "processed" and moved on to another island and so they will not receive their result in time.  If the HIV result is positive then there are further problems once the patient has been tracked down, as they have been transferred to places such as Nauru where treatment access and roll-out is sub-optimal.  He then described how HIV positive refugees on the island had often been placed in the "White Building" - usually reserved for people with behavioural difficulties.  His experiences really highlighted the challenges faced by clinicians and patients alike, in difficult health care settings, in stark contrast to my own, well resourced Sexual Health Clinic in Sydney.

Then in the second session Dr Kathy Petoumenos presented findings from the ATRAS Study Group: The Australian HIV Observational Database Temporary Residence Access Study, of which several patients from my clinic have been gladly enrolled.

The NAPWHA group engaged various pharma companies to provide free ART to 180 medicare-ineligible patients for up to 4 years.

This study aimed to determine reasons for Medicare ineligibility, time to become eligible for HIV treatment on Medicare, and assess their long-term clinical outcomes once on ARTs. Enrolment was from 2011 - 2012. Results from the 24 month findings were presented.

Interesting results from baseline showed that 73% were male, most common visa status was Student Visa (34%) and 63% of the cohort had experienced prior ARTs (either as self-funded, trial participant, origin country or compassionate access).

Encouragingly over the period of the study, the mean CD4 count increased from a baseline of 376 to 534 at 24 months. Even more pleasing was that the percentage of patients with an undetectable viral load increased from 47% at the start of the study to a fantastic 94% at 24 months, with 100% of females achieving undetectable viral load.

So far 74% of participants have dropped out as they became Medicare Eligible, 17% have gone overseas and 9% were lost to follow up. Students were least likely to have stopped requiring ATRAS medications.

In the 2nd part of the presentation the group attempted to estimate cost benefit of expanding ARTS to all medicare-ineligible patients. The survey findings estimates there are approximately 450 medicare-ineligble HIV clients in Australia.  After 2 years patients with a detectable viral load reduced from 53% to 6%.  i.e. a 93% risk reduction in onward transmission of the infection.  Thus 81 new infections would be averted/ 5 years. 

Mathematical modelling using these figures shows that expanding ARTS access and treating all the temporary resident HIV+ population was determined to be at least cost-neutral - i.e. it saves as much as it costs.   Of course, the public health benefit and the benefits to the HIV-supressed individuals alike is so much more than that.

Aaron Cogle (Exective Director for NAPWHA) pointed out that medicare-ineligible people are not recognised as a priority population nationally, this and other federal and state barriers to ART access need to be tackled imminently.   If universal test-and-treat policy is to be realised then this population needs to be included.

Atras Ceases Nov 2015.

Sadly I was unable to attend the last presentations in this session as I had to catch my flight.

What a great conference, see you all in Adelaide (and Rio) and thanks to all or any who managed to read this far into my blog!!

 

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You know how you used to take your conference notes on the notepad in the conference satchel?  

What did you do with them? Mine are sitting in a pile on the bookshelf, along with all the abstract books from the conferences I've been to.  I don't think I've looked back through the notes more than 4 or 5 times, and I think I've looked up an abstract that I kinda remembered twice.

You might have moved on to taking your notes on a laptop.  Do you print them out?  Or file them away in a "conference notes" folder? or are they somewhere in your general documents folder with an obscure name like "Brisbane HIV Conf Sep 15.docx"?  I bet they probably don't get looked at much more than the notepads.

I've moved to taking my conference notes on twitter. It takes some practice belting out a 140 character tweet for important ideas in each presentation, but it has the great benefit of making it accessible - to others at the conference, but also to people who might be following at home, by following the official conference tag.

You can then use a tool like storify to aggregate your tweets into a single webpage - for easy sharing, and to refer back to (or not) later on.  My tip if you do this, is to aggregate them each night.  I tried to go back to my AIDS2014 tweets after a couple of weeks and it was much harder (impossible) to do easily.

Here's the collections of my tweets from the conference for you.

I hope to see more people doing it next year;  my request for the organisers is to make the official #hashtag shorter - how about #ashm16 or at least #hivaids16 please?

Day 1: https://storify.com/trentyarwood/hiv-aids-conference-2015-day-1

Day 2: https://storify.com/trentyarwood/hiv-aids-conference-day-2

Day 3: https://storify.com/trentyarwood/australian-hiv-aids-conference-2015-day-3

 

Tagged in: HIVAIDS2015

Posted by on in Social and behavioural research
Friday final words

RELATIONSHIPS AND COMMUNICATION

These words were repeated today in all sessions I attended.

What is a relationship for gay men?

How successfully do gay men communicate with each other? And why is this important for HIV and STI prevention?

The session today titled Gay Men, Sex and HIV Prevention thoroughly explored the various combinations spoken of relationships that gay men talk about in the Monopoly study. Different aspects such as Agreement whether formalised or implied, which cohort of gay men are more likely to make these agreements and why or how are they broken or bended?

What did I learn today?

WORDS words Words!!

In USA they use " steady" instead of "regular" and the chasm between regular and casual is very wide in relation to what the researchers say gay men are negotiating.In Australia the fallaback option is monogamy,  so if it is not then what is it? According to one researcher about three quarters of men in the study said they had a regular partner , but only 40% of the men also stated that they were in a relationship;  so men are often in a relationship with a fuckbudy, where does this behaviour get discussed in relation to HIV transmission risk? Typical consultations may miss these types of relationships if prior knowledge of regular partners is known.

Relationships according to how old a gay man is was then explored, with the aversge age of gay men in the Monopoly study being mid thirties , the question was posed do young gay men behave or think they behave the same way?

Generally the evidence was that young gay men had fewer explicit agreements, it was surmisec that they assume monogomy until it wasn't! Young gay men were less likely to discuss HIV risk reduction and relationships were of shorter duration. However somewhat surprising engaging in condomless sex was relative similar despite the age.

The use of the term now condomless instead of unprotected sex was discussed, this term accurately describes the act of sex, however, any person may have taken other steps into reduce the risk of HIV and STIs by choosing who to have sex with, know the Viral load status of themselves and sexual partner or even take PrEP.

This was discussed by Martin Holt who presented results that HIV positive men, HIV negative men both took other measures to reduce the risk of HIV transmission, with knowing their undetectable  viral load as the most commonly practiced method. A question from the floor added about what do we know about those who are unknown or not tested; it was thought that these men assumed they were negative.

Then onto the lively session on PrEP

In a  nutshell: IT WORKS, IT IS REASONABLY SAFE, GAY MEN WANT TO USE IT, SOME GREAT GPS ARE CREATIVE IN SUPORTING CLIENT CHOICE AND ACCESS AND DEMAND IS GROWING. WHAT WE NEED IS ACCESS SOONER THAN LATER AND RESEARCH INTO THE LONG TERM EFFECTS.

Tagged in: HIVAIDS2015

 

I attended the talk by Dr Janine Trevillyan titled: Management guidelines for HIV-related Co-morbidities result in increased screening but no change in Primary Prevention Implementation.

Janine described an audit conducted at Alfred Health, Melbourne comparing compliance with local recommendations/guidelines for screening and management of cardiovascular risk factors before and after release of the guidelines.

The audit showed that compliance rates for sticking to guidelines for statin use pre and post intervention were similar and there were no changes in patients receiving a statin pre and post intervention.

Although routine blood pressure monitoring increased from 65% pre intervention to 88% post intervention, there was no change in antihypertensive use and no observed improvement in systolic blood pressure post intervention.

One interesting finding of the audit was that renal function was borderline (eGFR 60-90mL/min) in 51% of patients. Janine mentioned that this will be something that will be followed up as the implications of these findings are unclear and it will be interesting to see where the renal function of these patients is at in a few years.

Overall, the audit found that implementation of recommendations/guidelines can increase screening rates for cardiovascular risk factors but this did not translate into improved implementation of primary prevention therapies. Janine mentioned that a change in the model of HIV care provision may be needed.

These findings are important to me as a pharmacist involved in the care of patients at an ambulatory HIV clinic. We have recently implemented a pharmacist review at annual health checks for patients taking combination antiretroviral therapy (cART) in my clinic. See poster number 12. Impact of a Pharmacist review during annual health checks in patients taking combination antiretroviral therapy.

A pharmacist review during annual health checks may help to identify patients not meeting the recommended cardiovascular risk factor targets, bring these to the attention of the doctor and assist with their management.

 

 

 

 

Tagged in: HIVAIDS2015

Posted by on in Social and behavioural research
I attended the launch of HIV Futures 8
This is a survey about health, treatments, work, finances, sex and relationships of people living with HIV (PLHIV). 
 
The survey seeks to gather information from all people living with HIV, including gay and bisexual men, women, heterosexual men and transgender people. The survey will be open until 14th March 2016.
http://www.hivfutures.org.au
 
Please recommend this survey to all people you know living with HIV.
Tagged in: HIVAIDS2015

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Most of my lunch periods have been taken up listening  to the various speakers and organisations that have appeared here during the conference.It has been both thought provoking and engaging.

I hope this continues at every conference .

I shall look forward to it.!!!!!!

Tagged in: HIVAIDS2015

Posted by on in Public Health and Prevention
 
At the lunchtime AFAO community hub today, Brett and Phil outlined how 2 Spirits work in culturally appropriate ways with the whole of community. They highlighted how some poorly set up programs may attempt to buy health outcomes, rather than working collaboratively and empowering community to take control of their own health outcomes.
 
Michelle Tobin - Provided background to the Anwernekenhe (National HIV Alliance) Conference which will be held in Alice Springs 12-14 November 2015. Link to the conference website - http://ana.org.au/A6/

 

Tagged in: HIVAIDS2015

Posted by on in Social and behavioural research

I attended an excellent talks this morning by Steven Philpot on the fine line in changing agreements between gay men when it was about monogamy.Steven utilised   the Monopoly results that gay men will negotiate changes in relationships,there was also a lot of internal conflict about this subject with a lot of couples,most men usually change their relationship from monogamous to an open relationship.

At the conclusion of the talk Steven reiterated that communication was vital in all relationships.

Benjamin Bavinton also provided an excellent talk during the session on the Definition of Partners.

Partners are either described as either regular or casual,but I would like to know when a f!ckbuddy becomes a relationship.

Approximately 60% of gay men have a regular partner,half of these were monogamous while the other half have a regular partner and casual partners.Most gay men in the Monopoly study were found to be in an open relationship. Condoms were much less likely to be used in an relationship,than they were with f!ck  buddies.The majority of me met there partners online.Transmisions were more likely to come from f!ck buddies.

Garret Prestage provided a good talk on age and relationships and it was heartening to hear that us oldies are much less risk takers than our younger counterparts.Garrett once again reiterated that most regular partners didn't use condoms.That being said it means the risk of transmission  is greater if we trust each other in a relationship.

Martin Holts talk was perhaps the most engaging as he spoke about the use of Viral Load undetectable as a means for condom less sex,he also identified serous orating as another means for condomless sex. Martin identified that at least 75% of men are practising at least one strategy to avoid HIV.Serosorting is now common as a means for condo less sex.

1 in 5 gay men now have condo less sex

41% of these are HIV positive 

21% are HIV negative

19 % are untested.

The most common strategies employed by groups for condo less sex are if positive utilising an undetctable status and Serosorting ,if negative utilising Serosorting and condoms

Benjamin reiterated at the end of the lecture that with guys who have an undetectable viral load the risk of transmission is low.

A very thought provoking session

Tagged in: HIVAIDS2015
What do we know that we do not know?

On Thursday afternoon, under Theme B: Antiretroviral Therapy, things moved up a gear, with back to back presentations touching almost every aspect of the ART and the long term complications. Dr David Nolan from Royal Perth Hospital gave a thoroughly captivating revision around HIV treatment. He gave a brief account of the pre, early and late HAART treatment options, how things have evolved in terms of the choices, co morbidities, tolerability and toxicity.

He reflected on the contemporary challenges around decision making in clinical practice, how we can factor in the newer therapies and novel diagnostic approaches in our existing treatment and screening paradigms.

What do we know that we do not know?

David argued that despite of having potent ARTs with superior virological efficacy, we don’t have enough evidence to guide us on how to screen, monitor, and subsequently manage the emerging associated co morbidities including HIV neurocognitive impairment, chronic immune activation, and increased risk of malignancies.

What don’t we know that we do not know?

David threw up some very topical questions with both ethical and public health implications. Does it matter that there are things we don’t know? Should we change ART regimen just because we have newer drugs? What if HIV patients with sustained viral suppression do not want to change their old medications?

These are very complicated and yet practical questions, and we still do not  seem to have a simple answer. With discovery of newer, safer and simpler ART regimen, we are likely to find ourselves in a situation where we might simply not have enough evidence to guide clinical choices when it comes to changing or switching regimen. In that case he concluded that we might simply accept the fact that there will always be unknown unknowns.

He also discussed the rationale of ART treatment intensification (using Maraviroc for example) and what should be realistically expected. He pointed out that current evidence indicate that treatment intensification makes little difference in some of the important prognostic clinical parameters like viral load and immune activation markers. It does not appear to impact on viral reservoirs and residual viremia which tend to be established early following primary HIV infection. He posited that, in absence of robust evidence for treatment intensification, the seemingly logical approach will be to start treatment early following seroconversion.

This was arguably one the most thought provoking presentation I have attended in this conference. It raises some of the difficult issues clouding the field of HIV and ART treatment and long term treatment outcome. Obviously, there are things that we do know, and things we have been doing well in improving our knowledge and understanding of how ART works.

Perhaps, It is time to start thinking about how do we integrate the use of monocyte activations markers like sCD14, in the standard of care for our patients.  For the next few years it will be pretty much about the known unknowns and the unknown unknowns that will really determine if we are going to win another important dimension of this epidemic when every HIV patient has undetectable viral load.

Presented by Clara Brown.

As we are aware there are people living with HIV who are also co-infected with Hepatitis C. In Australia approximately 1 in 8 people living with HIV are also co-infected with HCV. 

Clara discussed how there is a disparity between those that are mono- infected and those that are co-infected and the number of those that have initiated early administration of ARV's for HIV. The rates of co-infected initiating or are on ARV's are much lower, despite the change in recommendations of early initiation of ARV's for HIV.

There are significant unmet needs for those that are co-infected with HCV. Often this minority population may have chaotic lives, not engage in health services, have financial difficulties, and may have difficulty with medication compliance. Clara discussed issues surrounding the need for wider Alcohol and Other Drugs services, Primary Care services, Allied Health services, as well as the ongoing issues surrounding stigma.

It is hoped that we can help this minority of a minority group improve their health outcomes and quality of life.

Tagged in: HIVAIDS2015

ASHM Conference 2015 – Take home messages from a GP

 

The 2015 ASHM conference displayed all the teamwork I saw at the first conference which I attended 21 years ago.  Great presentations and choices in themes. There was friendliness and a range of stakeholders and an ongoing respect for the roles and hopes of the different parties. The meaningful involvement of all the stakeholders and especially those most affected by blood borne viruses is unique to ASHM stakeholders and I have not seen such teamwork in all the branches of medicine I know.

In a nutshell, the big message for GPs from this conference is PrEP, PrEP and PrEP. PrEP means pre exposure prophylaxis. GPs will need to get ready for what appears to be a huge ground swell of demand for PrEP. They will need to know the use of Truvada for HIV sero negative gay men.  Truvada for PrEP is not currently approved by the TGA and the PBS. So, GPs working in the MSM health area will need to know what mechanisms exist for current access.

Some issues will exist for a GP who considers prescribing PrEP, but the figures offered at this conference strongly suggest the outcome for ser negative MSM at high risk of HIV infection and  on  Truvada will be a lowering of new HIV cases.

The United Nations 90%:90%:90% goal concerning HIV was often referred to  in presentations. The UN goal is:-

- 90% of people living with HIV will know their HIV status.

- 90% of people living with HIV will receive sustained anti retroviral therapy.

- 90% of people receiving antiretroviral therapy will have durable viral suppression.

A big message was that early ART treatment is recommended - start at the time of diagnosis. Regardless of CD4 count. Many presentations supported this. The START (Strategic Timing of AntiRetroviral Treatment) Study presentation concluded that:-

=Combination antiretroviral therapy (ART) should be recommended for all HIV -persons regardless of CD4+ count.

= The START Study results align the benefits of ART to the HIV-positive individual to the benefits of ART in reducing the risk of viral transmission from HIV – positive persons to non- HIV- infected individuals. So, clinicians should regularly discuss the current state of knowledge regarding when to start ART with all individuals with HIV who are not yet on ART.

 The conference presentations reviewed current recommended ART treatment and some of their toxicities. An issue resulting from this is that all decisions to start ART should be made by the individual with HIV, in consultation with their healthcare providers and on the basis that they are fully informed and supported in their decision making. Patients makes the decisions and doctors give  good advice  for the  patients to  base their  decisions on.

The conference highlighted the importance and difficulties in long-term follow-up of people with HIV. The option in the future of a national notification system might help in this regard, but there are currently greater efforts to evaluate past and current treatments.

 Data at the conference strongly showed that mucosal damage from STDs lead to more easy HIV infection and the vigilance to treat STDs to decrease HIV spread cannot be over emphasised.

 The new treatments for Hepatitis C genotypes 1 and 3 with daclatasvir and sofosbuvir have been approved by the TGA and are awaiting PBS approval.

 Victorian data suggests that in Victoria, HIV and STD notifications are rising. There is evidence of ongoing increase in condomless anal intercourse with casual partners. There are also additional risk reduction practices in use in the community.    

 Geoff Symonds gave a presentation on gene therapy treatment for HIV. I found this fascinating and wonder how the role of gene therapy will pan out in the future. Great potential there.

 At the ASHM AGM an overwhelming number of members voted to change its formal name and affirm its current role in covering HIV, viral hepatitis and sexual health. The new name is the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine.  The good news is the logo and the associated word ASHM stays there as well.

 ASHM delivered a great conference.

 

 Darcy Smith

Tagged in: HIVAIDS2015

Blood Pressure Targets IN HIV+ patients

Again another very interesting session from a GP perspective. 

Dr Shanti Narayanasamy discussed the challenge of meeting BP targets in HIV positive outpatients.

The background to the problem is concerning; high BP accounts for 45% of heart disease mortality and 51% of stroke deaths. Rates of hypertension in people living with HIV in Australia is approximately 20-25% and those affected have higher rates of myocardial infarction than the general population.

This cross sectional, retrospective study examined whether HIV positive patients attending an outpatient clinic who were diagnosed and treated for hypertension were meeting blood pressure targets as per the Heart Foundation guidelines.  Please see below:

People with proteinuria >1 g/day (with or without diabetes) < 125/75

People with associated condition/s or end-organ damage:* • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA < 130/80

People with none of the following: • Coronary heart disease • Diabetes • Chronic kidney disease • Proteinuria (> 300 mg/day) • Stroke/TIA < 140/90 or lower if tolerated

Of the 69 patients studied, 97% studied were male. Of these 48% met the target BP and 59% had end organ disease from hypertension. Most of these patients were treated with ACE-i medications (no: 39). Most patients were treated with monotherapy (70%) and 30% were taking more than 1 anti-hypertensive. Of the patients that had end organ disease only 68% had seen either a cardiac or renal specialist as per the guidelines. Of those that had seen a specialist; this was correlated with better BP control.

Those patients that were virologically suppressed had better BP control. This could be attributed to overall better medication compliance. Older patients also had better BP control.

This raised the question of whether there was some reluctance/inexperience of the ID physicians or general practitioners involved in these patients care to up-titrate hypertensive management when necessary.

Certainly this appears to be an issue that is likely faced in a number of different settings and was a great way to raise the awareness of meeting BP targets and involving specialist opinion when required.

 

Tagged in: HIVAIDS2015

This morning I read the headline ‘world leaders pledge to achieve gender equality by 2030’.  This was timely given I had just attended the session entitled ‘Bingo: The use of targets in HIV policy’ chaired by Professor Heather Worth, the day before. This headline reinforced the arguments put forward in the session about use of targets. Can we really achieve gender equality, something that is tied up in complex political systems, social norms and beliefs within the next 15 year? The target filled me with hope and gave me an extra spring in my step as I headed to the conference. But the points made at yesterday’s debate lingered. Are we really able to achieve such aspirational targets such as UNAID’s 90-90-90 target in which 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression within the next 5 years? And if such targets aren’t achievable should we be setting them?

 

The panel put forward differing argument on a debate which essentially focused on aspirational targets vs. more realistic evidence based targets. Professor Charles Gilks spoke about the 3X5 Initiative and said that whilst the target of 3 million people living in low and middle income countries being provided with ART was not achieved by 2005, this aspirational target provided a driving force and focusing of efforts so that it was achieved two years later in 2007.

 

David Fowler, a self-proclaimed cynic when it comes to aspirational targets argued that targets should be evidence based and realistic. Whilst Professor Peter Aggleton put forward the notion that targets have been reduced to ‘sloganeering’. Peter indicated that he wasn’t opposed to aspirational target setting at it ‘motivates our hearts and head’, but also argued that targets need to be realistic, owned by the community and that we also need to look beyond targets and be driven by ‘doing the correct thing’.

 

There were other interesting discussions about how to set targets with Charles arguing they need to be realistic and based on the cost required to achieve them. Midnight Poonkasetwattana proposed that global targets are inappropriate as we need to look at individual community wants and needs rather than producing sweeping global targets.

 

The debate reminded me of another great session by John Kaldor I had attended. John had touched upon what he considered unhelpful dichotomies in disease control such as; technology vs. environment, action vs. evidence, government vs. community driven, medical vs. social and public good vs. human rights. He argued that these things should not be pitched against one another but recognized as both helpful and necessary. I couldn’t help but wonder whether aspirational vs realistic targets should be added to the list and whether it is possible that they could be one and the same thing? What do you think?

 

Tagged in: HIVAIDS2015

I really enjoyed the sessions today on co-morbidities and as a S100 general practitioner found this very useful. The discussion re bone health was especially interesting to me given a number of my patients have low BMD.

Professor Jennifer Hoy outlined practical management and screening of bone disease in HIV. Osteoporosis is a silent disease until fracture occurs and people living with HIV have a higher risk of low BMD and fragility fractures than the general population. This is likely due to lifestyle risk factors, low vitamin D levels, HIV induced inflammation and the effect of ART.  The question is who should be screened? Which tool should be used? When should we start screening and how often should we be screening our patients?

Who should be screened? All HIV positive individuals over the age of 40years, those with a history of fragility fractures, those taking corticosteroids for more than 3 months at doses of greater than 5mg per day and prior to ART initiation.

Which tool do we use ?Using the FRAX calculator ( https://www.shef.ac.uk/FRAX/tool.aspx?country=31) calculates the ten year probability of fracture with BMD. However the FRAX calculator while useful has not been validated in the HIV population. High risk patients should have a DEXA scan. However DEXA scan can only be accessed if there is a history of previous low BMD or previous fragility fracture/fracture with minimal trauma, if there is a history of chronic liver or renal disease, proven malabsorptive disorder, history of rheumatoid arthritis, thyroid excess states and in patients over 70 years of age. It does make it difficult if your patient does not fall into this category and alternatives to DEXA include the 'Measure Up Mobile Dexa Bone Health'unit, quantitative CT scan and heel ultrasound.

DEXA screening intervals are based on the baseline screening result. For normal-mild osteopenia this would be every 5 years and for more advanced osteopenia every 1-2 years. Professor Hoy mentioned that there was insufficient evidence for more frequent screening for those on certain ART regimens i.e. tenofovir.

In terms of treatment for those with fragility fracture or low BMD this includes:

- adequate dietary calcium

- ensure they are vitamin D replete

- lifestyle modifications ie smoking cessation/alcohol reduction

- exclude secondary cause of low BMD

- discontinue or change ART regimen if appropriate

- initiate bisphosphonates under the same criteria as general population

This was a very informative session and information that will be very useful in my position as a GP

Tagged in: HIVAIDS2015

You could almost - almost - be forgiven for feeling like the biomedical developments in HIV have come to their hump-day.  Vaccines research hasn't been as successful as we had hoped, microbicides are good but not great. New drugs are refinements (and handy combinations) rather than truly novel compounds. Cure still seems so painfully far away - although there certainly has been progress announced this week - see https://theconversation.com/cancer-drug-promises-to-break-down-barrier-to-hiv-cure-47558 for some discussion.

We have excellent treatments, which we now know without doubt are good for patients, good for partners and good for the population. In Wednesday's morning plenary session, Mike Cohen emphasised his belief that there is now no justification for delaying therapy.  Long live test and treat.  Prevention studies continue to add weight to arguments for Treatment as Prevention and Pre-Exposure Prophylaxis. 

The Wednesday afternoon plenary session and Friday's session on migration were reminders to step back, and consider how lucky we are in Australasia, but that this is not universal.  HIV is a global disease; our 27,000 Australians living with HIV are but a tiny fraction of the 40 million people infected worldwide.  People in low and middle income countries are not only living with HIV, they are still dying from it.

 

Clearly this isn't because there aren't treatments as our local experience shows.

People are dying because of lack of access.

 

In the developed world, we have has some success in fighting legal discrimination against people with HIV;  this is not the case everywhere.  Laws criminalising homosexuality or injecting drug use can only act as a barrier to Test and Treat.  Thursday's session on Criminalisation highlighted the dangers posed by laws such as these. The HIV sector can stand tall for their efforts in fighting these laws - to improve health and to remove stigma.

An area of advocacy that, as a group, we often don't consider, however, is intellectual property and global trade.  Charles Chauvel from the United Nations Development Project gave an excellent talk on the risks of IP laws for global access to medication.

Antivirals are expensive; and rather than becoming cheaper, there is a very good chance that these IP laws, coming into effect as part of free trade agreements, will limit the development and availability of generic antivirals, which are so crucial the low and middle income countries.

 

Australia is a world-leader in HIV research. While we look to a cure, tantalising us on the horizon, we should all remember to pause and look back, so we can make sure that no one is left behind.

 

Tagged in: HIVAIDS2015

 

After two fascinating talks by Dr. Patrick Mallon and Dr. Geoff Symonds around great medical strides being developed, another facet of care and project development shone in the plenary session.

 

Andrew Jolivette’s elegant talk brought focus back to how we as practitioners and researchers can widen our perspective by weaving past social constructs, acknowledgement of generational impact and group solidarity into how we view and address health concerns in today’s world - especially in light of how our world's cultures are blending and evolving.

 

This session tied in quite nicely with James Blanchard’s talk and ‘Mega Model’, exploring windows of opportunity and individual timeline trajectories. Jolivette goes further, asking us to examine windows of opportunity and change for past generations – to include the impact our own previous generations have made on Indigenous cultural practice and social perception of self and others.

 

Again, the one-size-fits-all approach is noted as not working. Jolivette encourages us to work inclusively and collaboratively alongside groups to build community solidarity and ‘weave’ projects to improve outcomes in health and well-being.  He argues the incorporation of research justice and Indigenous methodologies can help build better programs while challenging identity and behavioural categorisations that continue to pigeonhole gender, sexuality and multiracial individuals/ populations.

 

In an interesting train of thought, he also asks we approach research as an act of ceremony to build cohesiveness while remembering the context some indigenous populations view research and how they benefit from projects.

 

Jolivette also notes the importance of peace of mind and the acceptance of disease as a process of healing –and that healing is an ongoing process of wellness.

 

I think there are strong parallels to be drawn between Native American experiences and the situations Australian Aboriginal peoples face. There is great potential for us to better tailor programs and I will be paying particular attention to what is happening in the gaps and blank spaces in program frameworks and research.

 

Andrew Jolivette’s talk today challenges all of us to examine the dynamics in public health programs and process implementation – and most importantly, finally acknowledge individual difference as a societal contribution rather than a hurdle.

Tagged in: HIVAIDS2015

This morning we saw a series of presentations from the Monopoly Study, which is a national Australian study that looked at how gay and bisexual men think about and conduct their relationships. They looked at whether gay men have explicit relationship agreements with their regular partners, particularly around issues like monogamy. They also presented finding around why and when couples change their relationship agreements from monogamous to open and vice versa.

Some interesting points included:

  • There is inconsistent classification of sexual partners in the literature. Generally in Australia partners are classified as either "regular" or "casual", but the definition of these categories is inconsistent. Particularly, they highlighted that "fuckbuddies" can be placed in either the regular or casual partner category, and perhaps clinicians and data collectors need to consider this group of partners as separate to either regular or casual partners.
  • Young men have shorter relationships than their older counterparts.
  • Young men tend to assume that being in a relationship means that the relationship is monogamous, so they don't tend to have explicit relationship agreements. There was some discussion on why this may be so. One thought was that these days young gay men tend to have more heterosexual friends than in previous generations, and hence they tend to have views on relationships that mirror their heterosexual counterparts. I think that perhaps this may also underlie the change in relationships amongst young heterosexuals, where it seems that young heterosexual couples now more often make explicit agreements around monogamy vs having an open relationship. Another possible contributor to the lack of relationship agreements among young gay couples is the ongoing marriage equality campaign. I think it's fair to say that the marriage equality campaign in Australia tends to promote monogamous gay relationships as being "the norm", and tend to ignore the many other possible types of gay relationships. Such campaigns may have altered the perception of young gay men on what is expected in a gay relationship, and hence they don't feel the need to have an explicit agreement.
  • Older men tend to have explicit relationship agreements. The explanation offered was that many gay men over time come to the realisation that relationships are complex, and that the supposed "rules" dictated by social norms are not concrete. As such, they feel that it's important to discuss the needs of both partners, and that an agreement is reached, which is may subsequently be revised when the couple's needs change.

So what does all of this mean for clinicians?

  1. It may be useful to ask patients about fuckbuddies when talking about their relationships, and to ask what agreements people have with their fuckbuddies. In the "casual" vs "regular" linguistic dichotomy, fuckbuddies may get lumped in the "casual" category, and thus not get the attention they deserve.
  2. We must ask young gay guys whether they have explicit relationship agreements with their regular partners and fuckbuddies, as this data shows that they often assume that their relationships are monogamous. The assumption of monogamy may place them at increased risk of HIV and STIs.
Toxicities

Lovely morning plenary by Paddy Mallon discussing ART toxicities. 

With the lofty ambitions of 90-90-90 upon us, there will be increasing numbers of people starting ART at higher CD4 counts. Given that all the regimens we would be prescribing have excellent efficacy, toxicities & tolerability is now firmly back in the spotlight. 

Interesting point comparing tolerability and toxicity; in general, tolerability (side effect profile) is easier to identify and often brought up by the patient themselves. Patients have been known to put up with mild/moderate side effects if they are satisfied with their regimen. 

Toxicities are often silent which means as clinicians we need to have appropriate monitoring strategies if we are to stay ahead of the game. 

Paddy briefly talked to the PIs and lipoatrophy (now essentially obsolete), as well as some PK data suggesting the PIs may not have the level of association with insulin resistance or CV risk once thought.

Efavirenz got a mention - it's definitely out of favour now, ostensibly due to its side effect profile (dreams, rash, dizziness), though some of the data for abnormal dream is fairly subjective. 

The main toxicities Paddy focused on were the big 3 silent toxicities due to the NRTIs

1. CV risk due to abacavir:

- Paddy's opinion is that the the evidence is conclusive with a number of studies, including the recent US NA ACCORD (palella 2015) showing a hazard ratio of 1.95 for AMI.

2. bone and kidney health due to tenofovir

- bone health seems to be predominantly lost in the initial 48 weeks on ART, implying that it is the ART, rather than HIV alone, which leads to decreasing BMD and subsequent increased fracture risk. Cessation of TDF leads to increased BMD.

- renal function - consideration for TAF is important - the cost will need to be taken into account.

And into the future?

- cost is and will remain an issue

- should we drop the NRTI altogether?

- the silent toxicities will become less silent as our HIV population ages

 

Thanks for a great summary of the topic

 

 

The pending introduction of a new formulation of tenofovir, a prodrug of the original formulation, raises the question of equivalence in terms of outcomes and virological suppression and adverse effects.  Don Smith and Mark Bloch presented data clearly showing that the newer formulation of tenofovir - tenofovir alafenamide (TAF) is superior to the original tenofovir disoproxil fumarate (TDF).  TDF, while a very effective agent, may cause clinical renal toxicity and adversely affect bone marrow density.  TAF is a novel prodrug that has a 90% reduction in serum plasma tenofovir levels and hence has the potential to reduce the adverse effects seen with TDF.

The speakers presented results of the GS-292-0109 study which looked at tenofovir disoproxil fumarate (TDF) 300mg switch to tenofovir alafenamide (TAF) 10mg in a cohort of well controlled patients at 48 weeks on once daily optimised background therapy.  1196 patients were randomised 2:1 to receive TAF based therapy to TDF based therapy with virological success occurring at least equally across both groups indicating non- inferiority.  Further positive results were seen in the TAF group where Statistically significant increases in BMD and multiple tests of renal function compared to those patients on theor prior TDF based regimen.  Lipid profiles however favoured TDF based regimens.  These results support the preferential use of TAF, especially in those at risk of metabolic and/or renal adverse effects.......well when it becomes available!

 

Tagged in: HIVAIDS2015

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

ASHM ASHM