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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Day 2 of the conference was informative, fun and interactive. Opportunities to use smartphone technology to interact using live polls added to the experience. Here are my key GP take home messages from day 2.

1. Hepatitis C is curable and can be eradicated! At present only 1% of people with Hepatitis C are offered treatment. There is an urgent need for more community prescribers. The new DAA should be PBS listed by the end of this year. These drugs offer 8 week treatment times, are well tolerated, and have minimal drug interactions. Regimens will be interferon free. These drugs are highly effective (over 90-95% cure rates, even in advanced cirrhotics and HIV/Hep C coinfected populations).

GPs will play a major role in the eradication of Hep C. Treatment needs to be accessible and affordable globally.

2. Integrase inhibitors should now be first line agents of choice for ARV naive patients. They have outperformed EFV, DRV, ATV and just about everything else. They are well tolerated, suppress viral load rapidly, have few drug interactions and have a good metabolic profile. They are also increasingly available in 'one pill daily' regimens.

3. We need to include the transgender community in our sexual health campaigns and research (see my blog "PASH" 17/9/15)

4. We should be open to HIV self testing, in the US HIV self testing kits were well received by patients, and available by voucher, post, sex on premises venues, and even from vending machines in car parks! Patients who tested positive did link in with care, and these tests offered a convenient, out of hours testing opportunity, potentially reducing barriers to HIV testing.

Looking forward to day 3!

QuAC launch of PrEP programme and why, oh why, can't my fellow GPs always help MSM patients

QuAC Launch of PrEP Campaign and why cant my fellow GPs always help MSM patients?

It was  heart warming  and praiseworthy to  see the  Queensland AIDS Council (QuAC)  launch what one QuAC employee told me was Australia’s first PrEP public  education  programme in  Australia..

 In a segment of the AFAO Community and Advocacy Hub forum, QuAC passionately and convincingly launched their education programme aimed at HIV sero negative gay men who consider they want or need extra protection to minimise HIV infection.

Blue and black PrEP T-shirts were prominent and panel members gave personal accounts of their use or desire for PrEP.

 I am a GP and sadly for me one panel member vividly told of the difficulties he was encountering with his GP to achieve PrEP. The panel member recalled the concern of the GP to prescribe a medicine outside “government recommended” principles. The panel  member said he  provided written  material  to the GP  and in  the end he was referred to  a Sexual  Health physician  for a definitive decision – but  not without being warned the  Sexual  Health  physician decision  would be final and after that decision,  the panel  member/ patient “should let the matter rest”. My goodness!

 I had hoped his GP and all the 25,000 GPs of Australia could manage such a request.

 Another panel member said MSM patients have had to “drag” GPs along to an “acceptable point of view” for many years.

 The dilemma of gay men seeking appropriate treatment from GPs needs further attention and debate and education in GP circles.

 The issue of how to find a GP who is sensitive to gay men was highlighted. Just how do a MSM client/ patient know they will receive modern, non judgemental, aware and informed advice?

 This is an ongoing problem, especially for remote and rural men.

 There is much education going on. It might be best to take GPs along with this swell.

 Well done, QuAC.  I admire your programme which sends the PrEP message to gay websites including SameSame, Recon, Gay News, Grindr and other popular gay internet locations frequented by gay and bisexual men.

PrEP has the potential to minimise the spread of HIV so all efforts to ease access need to be canvassed and supported.  The TGA and PBS should move their processes along – and hopefully they will, despite the bureaucratic processes and the inevitable pundits.    

Tagged in: HIVAIDS2015

Posted by on in Public Health and Prevention

DAY 5 for me as an atendee of both conferences.

Brisbane reminded us that it can rain and rain it has today. 

BE BRAVE BE courageous Was a theme I heard from two very different aspects of the issues up for discussion today.

Presentations discussing how best to harness the power, energy and wisdom of young people towards HIV health promotion engagement, were diverse and interesting. From the voices of young Ugandans, or Australian First Nation youth or same sex attracted young men already somewhat engaged in advocacy the take home messages were; get them interested, ask them what they know now, then ask them to come on board and  lead the way in working out how to engage their peers.But most of all do what they suggest- follow through.

This afternoons BINGO session about Targets for HIV policy once again drew out different opinions on the usefulness and relevance of  targets, one panelsit alluded to the meaning of random numbers anyway.

We heard plausible argument for inspirational targets that can push governing bodies or agencies for visionary levels or can be motivational for aspirations to be more tha "usual practice". Other arguments lauded that aspirational targets miss the current climate of resource limitations and allocation challenges; therefore the setting of targets must be effective. Effectiveness may mean targets based on developed modelling that mobilises resources to areas of most need, regardless of settings. Questions from the floor were thought provoking; what is the alternative? And what about those vulnerable people who do not have a voice to advocate for their issues to be considered.

This is where courage and bravery comes in advocates may need to be the voice of the vulnerable, health professionals may have to be in competition for the same dollars -which disease is more worthy?

Do we teach coleagues , students, managers to take lesons in political health as part of public health advocacy?

 

A great ending to a stimulating day of excellent information.

 

 

Tagged in: HIVAIDS2015

I attended the talk by Prof Sharon Lewin this afternoon titled ‘HIV cure research: current strategies and challenges’

Sharon started off by saying that sustained remission off ART is achievable. Some examples of this are the Visconti cohort and the Mississippi baby.

Early ART has a greater impact in limiting persistence of the HIV reservoir than later treatment (as found by Ananworanich and Chomont , Curr Opin HIV AIDS 2015). However, post treatment control is a rarity following ART in acute HIV infection and biomarkers to predict cure/remission are required (e.g. in the Swiss HIV cohort study, HIV DNA predicted time to rebound).

Sharon touched on latency reversing agents now in clinical trials e.g. HDAC inhibitors , TLR agonists, activators of NF-kB and others such as disulfiram.

Sharon said that activation of latent HIV was possible in vivo with HDAC inhibitors, disulfiram and TLR7 agoinsts but there is a need for more potent, less toxic and more specific agents.

Combination of agents (e.g. HDAC inhibitors and smac mimetics) as well as modulating immunity via vaccination or immune checkpoint inhibition are also in the pipeline and gene therapy is also an avenue to be explored.

After this talk I felt very inspired about the work Sharon and other researchers searching for a HIV cure are doing!

 

 

 

 

 

 

 

Tagged in: HIVAIDS2015

Posted by on in Social and behavioural research

A summary of today (Thursday 17 September 2015)

Jeffery Klausner - new technologies and innovations to facilitate HIV prevention, testing and care

The future of health care is with mobile technology.

Primary prevention - exposure reduction

Directed us to look at a YouTube video (Willie and Twinkle) as being a good example of sexual health education for young people.

Healthvana - An app that acquires data from laboratory or clinician as evidence of health status. The app keeps the info for 3 months and men can use the information for sero sorting.

Gamesmanship is a way to engage people in health - gave example of a quit smoking game. Below are some other examples

 Play itsafe - on line game, with an avatar

Epic allies - game to improve medication adherence for young HIV pos black MSM.  Good for hard to reach populations, who don't have strong social support.

I got your back 

Secondary prevention

Testing

HIV and testing locators - to find and make appointments on line

Self testing - modest uptake in USA. Placed vending machine in car park of West Hollywood gay and lesbian centre. Is an option for people who don't want to engage with clinician. 

Vouchers - developed voucher system in partnership with pharmacy chain. 

Banner ad on Grindr - people don't take notice of banner ads so bought Blast ads which people have to click thru - and then can select which method they wish to receive self test.

Adherence

Weekly SMS messages improved viral load outcomes - the use of SMS messages emphasised the importance of caring for the patient

Oregon reminders - can set up own messages

Vancouver research - sent weekly SMS reminders to people with Viral load >200 - this intervention improved VL rates over time

At the AFAO Community Hub at lunchtime the panel of Max, Dean and Harry provided Victorian perspectives on their community conversations, strengthening PrEP in the next NSW HIV Strategy,  and Max on personal and professional perspectives of PrEP and the importance of men having a range of different prevention strategies. 

Issues discussed by the panel were accessibility, cost and standards of imported drugs.

Challenges - Max reported many conversations helping people find the words to start the conversation with their doctor- many have a fear of being judged by their doctor.

Key messages from today are the importance of community involvement in prevention programs, and the usefulness of new technologies to work with at risk groups of people.

Tagged in: HIVAIDS2015

Posted by on in Social and behavioural research

Day 2 of the conference and there have been more thought provoking sessions. The afternoon "Drug and Alcohol Session" raised a number of issues for clinical practice and for future research and confirmed what I have been noticing in patient presentations over time, with more individuals reporting regular use of methamphetamine.

Mo Hammoud, Project Manager of the Flux study (Kirby Institute) and his talk on "Highs and Lows of Methamphetamine Use among Gay and Bisexual Men" referred initially to data from the HIM study with odds ratios for risk of HIV seroconversion being: 1.8 with methamphetamine use, 4.1 with erectile dysfunction medication (EDM) use, and 8.1 with both methamphetamine and EDM use.

In the Flux study, examining the relationship between EDM and methamphetamine use, Mo indicated that many men are using EDM for pleasure, that this may not be associated with erectile dysfunction, that EDMs were more commonly being obtained from outside the health system (online), and that men who use EDM are more likely to engage in condomless sex, group sex, and to use methamphetamine. The implication of this is that it highlights key indicators for HIV risk behaviours and transmission.  

In their research looking at methamphetamine use they found that over 80% smoked while around 30% injected, 30% used monthly, 13% weekly and 4% every day. When asked about reasons for methamphetamine use the top response was "for fun" (around 70%). The reported "highs" of methamphetamine use were ranked 1) had better sex (60%), 2) I felt happy, 3) had some great parties, 4) gained more confidence, 5) met new friends, and 6) brought me closer to people (40%). Conversely, the reported "lows" of methamphetamine use included a number of responses but with the top response (around 50%) being "had unsafe sex". Overall the men reported more highs than lows in their reasons for methamphetamine use. The research also found that condomless sex was significantly more likely with recent methamphetamine use.

Studies such as Flux are highlighting important isues to consider in targeting HIV transmission in certain groups but also possible aspects to focus on in working with individuals when trying to address methamphetamine use, providing better understanding of the likely reasons for use as well as the downsides of use. 

In my job as a clinical neuropsychologist assessing HIV positive individuals for possible cognitive impairment I am increasingly seeing people present with a mixture of contributing factors for cognitive impairment and with crystal meth use becoming more of an issue over the last few years. The session today focussed on use of methamphetamine and risk behaviours and provides important information to consider. Over time it would be great to see more research on the longer term impact of methamphetamine use by HIV positive individuals and also more funding and services to enable ready access to treatment for those seeking to reduce or cease methamphetamine use.  

Tagged in: HIVAIDS2015

There is ongoing optimism surrounding the evolving management for Hepatitis C.  But this is also tempered by the enormity of the epidemic of Hepatitis C around the world.  Whilst ~250,000 Australians living with Hep C will potentially have access to PBS subsidized highly effective directly acting antivirals in the coming months, there are still 80 million people worldwide living with hepatitis C with the vast majority in Africa (22 million) and Asia (12 million).  Many of these people do not know they have Hepatitis C (i.e. they are not tested).  We were also shown a sobering figure illustrating that the global burden from liver disease is increasing more rapidly than any other disease (including cardiovascular, respiratory, diabetes) and hepatitis C has now overtaken hepatitis B as the leading cause of liver-related morbidity and mortality in the world.   

An example of the mortality impact of hepatitis C was starkly demonstrated in a US study.  They showed that the median life expectancy was 78 years (without HCV or HIV), 60 years (with HCV) and 52 years (with HCV/HIV co-infection).  And as populations in high income countries like Australia grow older, the proportion of liver transplants and liver cancer due to hepatitis C continues to rise.

Well, let me end on a good note for those living in Australia.  We look forward to the first interferon and ribavirin-free single tablet regimen (Harvoni = Ledispavir + Sofosbuvir).  This drug has already been given to more than 200,000 people treated outside clinical trials and is proving to be a real game-changer for the traditionally difficult to treat patients with HCV genotype 1 (>95% SVR after 8-12 weeks in treatment naive).  Viekira-Pak has also been recommended by PBAC for those with genotype 1.  It is also exciting to see that pan-genotypic regimens like Sofosbuvir + Daclastavir has also been approved by PBAC for genotype 3.  Here's hoping that PBS listing will come in Dec 2015 or early 2016.

 

Jason Ong

Tagged in: HIVAIDS2015

Congratulations to Teddy Cook (ACON) and Jeremy Wiggins (VAC) for an important talk today about PASH, the Peer Advocacy network for the Sexual Health of trans masculinities. 

It took me a long time browsing through the ASHM program to find any content or posters addressing sexual health in the Trans community.

Trans MSM are often assumed to have low risk of STI's although this group are more likely to practice condomless receptive anal sex than other men. Trans MSM are often not included, and often deliberately excluded from research projects. During data collection the Trans community are often misgendered or expected to tick a 'transgender' box when they may identify as male, female, or non binary. Trans women are often misgendered as 'gay men'.
 
So it's not surprising that we have a lack of data about STI and HIV prevalence in Trans MSM. PASH aims to educate health practitioners, promote inclusive research, and provide health promotion and resources for transmen who have sex with other men. 

As health providers we need to lift our game and take action to prevent further discrimination and negative health outcomes for this often neglected group.

A great presentation, informative and concise. Thanks!

Hi everyone,

Another interesting and interactive panel discussion featuring Professor Jennifer Hoy, Dr Julian Elliot, Dr Mark Boyd, Dr James McMahon, and Dr Mark Bloch. This discussion built on earlier plenary session presentations on Theme B: ARV Guidelines - When and What to Start.

Three interactive clinical scenario on starting ART were presented to the audience and the panellists. These cases reflected the daily practical challenges facing clinicians and patients in deciding the best regimen to start that will optimize treatment outcomes with minimal side effects. Dr Mark Bloch pointed out that  the decision on what to start should be tailored to the patient, taking into consideration their presenting general health, medical history, concurrent medical conditions, life style, emotional and psychological wellbeing and  socioeconomic status.

It was interesting to note from the panellists that while for patient simplicity of the treatment regimen and toxicity are most important issues to consider in starting and continuing with medications, for clinicians the decisions on what to start can be very challenging. Clinicians always find themselves in situations where the existing guidelines do not provide them evidence based recommendations on what to start or when and how to switch from one regimen to another, or from one drug to another.

The question of Abacavir and the risk of AMI for patients with or without background risk of cardiovascular disease was highlighted as the perfect example where the current evidence is still contentious. Mark Boyd also highlighted another challenge facing clinicians when they have to manage patients who are generally not represented in clinical trials. He gave example of patients with reduced kidney functions (measured by eGFR) and the lack of evidence from randomized trials for the use of petentially nephrotoxic drugs like Tenofovir (TDF) or drugs which have been shown to impact creatinine clearance(Dolutegravir and Cobicistat).

The take home message from this session is that clinicians need to carefully engage and comprehensively review their patients before starting or switching ART. They need to make sure that their patients understand existing guideline recommendations and options available, the potential adverse events and toxicity for each drug(s) they are going to take. It is also important for HIV clinicians to work collaboratively with  non HIV clinicians, and allied health professionals in managing non-AIDS conditions. This will eventually optimize treatment outcome and minimize any drug–drug interactions and risk of non AIDS events.

The important ARV guidelines session featured 4 speakers and a discussion/scenario panel

We STARTed (sorry) with the START study preliminary results by Jenny Hoy. Jenny discussed the data we've all been looking at since it was released in May. Essentially, we can now confidently recommend ARV for all people diagnosed with HIV, regardless of CD4. The study was ceased early due the strength of results in both AIDS and Non-AIDS complications in the immediate ARV arm. The benefits were maintained regardless of age, gender, race, world location and CD4 and VL at entry to study. Worldwide ARV recommendations have updated accordingly. 

Next speaker was Julian Elliott who reminded us of other studies (TEMPRANO & CASCADE) which have shown similar data in terms of treatment benefit at higher CD4s. Understandably, the number needed to treat is greater with high CD4 counts.

As chair of the ASHM HIV guidelines, Julian re-iterated that the decision to start ARV, while recommended in all HIV infected patients, should be a patient & clinician collaboration. 

Mark Boyd was then tasked with summarising why the integrase inhibitors (InSTIs) are now first-line drugs. Pivotal and open label studies over the last few years have left no doubt that raltegravir, and more recently dolutegravir, show non-inferior (and often superior) efficacy, with minimal side effect profiles and a fairly high barrier to resistance. The tolerability of the InSTIs really make them an appealing option for almost everyone.

James McMahon concluded the formal presentations running through the important changes based on the updated DHHS guidelines. In short, Efavirenz - gold standard for a decade - is on the out due to side effects (dreams, dizziness, rash). In actual fact, it's been on the out for a while and prescribers have been updating accordingly, however the official recommendations have now followed suit. James spoke about Darunavir, a PI worth considering, but not reimbursable on the PBS criteria as a first line agent. 

The scenario based panel followed with the abacavir CV risk a main topic for discussion. The jury is still out. Most of us are not keen to prescribe abacavir, and thus Triumeq, if the CV Framingham risk is a concern.

Thanks for a good session! 

 

Tagged in: HIVAIDS2015

Teddy Cook and Jeremy Wiggins gave a talk on the inclusion of transgender men in the HIV response, which provided much food for thought for healthcare practitioners and a call to action for health policy makers.

The presenters raised concerns that trans men generally report significant HIV risk, yet are overlooked in the HIV response. They highlighted some issues in data collection that may have resulted in trans people not being accurately represented in HIV data.

Particularly, they made the enlightening statement that "Transgender is not a gender identity". Trans men have very different experiences from trans women, and have different health requirements, including different sexual health requirements. 

Also, health data collection does not accurately capture data on transgender people. For example, the Victorian Department of Health HIV notification form gives the gender options of "male", "female" and "transgender". By lumping trans men, trans women and genderqueer people into the same category, health data loses nuances that are important for informing health policy and health promotion.

Also, they highlighted some case studies illustrating how this simplistic gender categorisation has resulted in miscategorisation of trans people in HIV statistics. One case described a non-binary trans masculine person who was assigned female at birth who has sex with men, who was categorised as a heterosexual female on her HIV notification form. Obviously, in order to develop an appropriate public health response to address HIV risk in the transgender community, we need data that accurately reflects what is happening in the trans community.

The presenters suggested the following two-question gender classification in order to overcome some of these issues.

  • Question 1: What is your gender
  • Question 2: What gender were you assigned at birth

On a lighter note, Jeremy pointed out that a recent HIV testing campaign from Victoria did include a trans man. It's a fun campaign, so have a look at the video below:

 

Australia is on the way to reaching the UNAIDS 90-90-90 goal but is hoping to fill in the blanks around why clients are lost to follow up care.

Several sessions this afternoon attempted to assess individual linkage to care and identify factors around why +HIV patients disengage with care.

Individual reasons for disengagement were not surprising with 'Feeling well' and 'Too Busy' listed as the most commonly identified issues. Additionally, the lack of up to date contact details and phone numbers were also listed as an issue.

Predictors associated with a true loss from care were clients in younger age groups, individuals not on treatment, detectable viral loads and previous issues with treatment adherence. Additionally, there were signs drug use, specifically Crystal, was a factor in loss to follow up. There is a need for further examination into the influence of drug use on individual loss of care.

Increased and improved recall systems within clinic practices, additional care team support (presumably nursing and allied health members), better identification of clients at risk of care disengagement and improved inter-practice communication could reduce those individuals lost to follow up.

Tagged in: HIVAIDS2015

Paul Kidd is the Chair of the Victorian HIV Legal Working Group. 

In this session, Paul discussed the definitions of laws in Victoria which involve Human Endangerment and PLWH. POAR Guidelines are in place to intervene to protect Public Health. The focus of these guidelines are to achieve behavioural changes to protect human rights. The problem Paul stated is that once a HIV positive individual has had allegations of Human Endangerment made against them, their privacy is lost forever, and they are publicly shamed.

Paul discussed prosecution when intent and HIV transmission occurs. For ths to happen, it has to be shown that sex occurred, there was appreciable danger and HIV was subsequently transmitted. 

Unfortunately HIV is stigmatised as a "Dread" disease and unfortunately stigmatism is alive and well in the Courts. Jurors ignore scientific evidence because of stigma in the media. Stigma drives stigma.

The key points taken from this session are that we may be winning the battle with HIV for effective treatment and prevention, but not for stigma. Policy changes are needed for more just and compassionate treatment of people with HIV before the Law Courts.

Tagged in: HIVAIDS2015

A fascinating and compelling presentation from Charles Chauvel from the a Global Comission on HIV and the Law and UNDP.

Charles spoke of the higher HIV prevalence in countries where sex work, injecting drug use and MSM are criminalised activities. He showed some graphs which clearly showed the relationship between reduction in harm reduction programs and increasing HIV. Charles gave the example of the Philippines where harm reduction services for PWID were dramatically reduced and HIV prevalence in PWID increased from 1% to over 40% in just 6 years. Although there are likely other factors at play here it is still a staggering increase.

It seems that attitudes are changing at a global level and hopefully we will see an end to the 'war on drugs' as this can hamper our efforts to reduce HIV incidence as well as access to those at risk who may need testing and treatment. We need more of a focus on drug use as a health issue and also the social issues which can contribute to problematic use.  

As Charles stated in his presentation, law reform is an effective way to reduce HIV transmissions and its free!

Tagged in: HIVAIDS2015

Jeffery Klausner provided an excellent talk on new methods in the US and around the world.

Jeff spoke about the need to utilise modern media eg YouTube to better engage with people; it seems the days of brochures and information sheets are soon to go.

The internet now can provide condom delivery within an hour in most big capital cities.

There is the ability now to have your HIV Status verified by medical companies on gay websites to prove that you are telling the truth. You can also allow blood results to be verified so that you can prove you have an undetectable viral load.

The younger generation all seem to like gaming and there are now Apps which emphasise Playing it Safe and promoting condom usage and increasing adherence to taking your medications.

I know in Adelaide we have very little like these education initiatives and you usually get handed a brochure.

In regards to testing Jeffery discussed the importance of status awareness and that San Francisco had the highest on the world for this.

It seems in Australia we have been very slow to even introduce rapid testing, but thankfully now this is happening.

We should also be considering the HIV self test, thus creating more options for people

In San Francisco they placed self tests in Sex Clubs, Saunas and provide vouchers to get free self test kits at pharmacies.They also provided the means to order a free self test kits online thus creating even more status awareness.The utilisation of these test kits was good and seemed to encompass the people who would not or could not get to a testing centre.

A hugely interesting talk outlining the need for us to utilise new methods in educating and engaging with people

New technologies include:

  • SmS weekly messages about adherence and testing
  • Geo mapping of current outbreaks of STIs
  • Home PCR for testing of STIs and HIV and providing Tele Health for PreP

A hugely interesting talk!!!

 

Tagged in: HIVAIDS2015

Excellent plenary session lead by Ed Gane discussing an overview of the swift evolution of HCV over 25 years!

I've summarised the main points: 

- HCV first identified in 1989 as non A non B

 

Current epidemic

- 80-100 million (300,000 in Aust & NZ) and is overtaking HBV as liver mortality 

- infection leads to premature death - especially co-infected HIV/HCV

- the disease burden will continue to rise as infected (ageing) patients develop complications such as cirrhosis and liver cancer.

 

So, how do we eliminate HCV? 

Vaccination?

- genomic diversity (both virus & host)

- funding diminished now DAAs so potent 

- likely not to lead to eradicate HCV

 

Public Health interventions?

- eg harm reduction in PWID (syringe programs etc)

- can only do so much - decrease prevalence by 1/3 in countries which employ reduction methods ( and most countries don't)

 

DAA therapy?

- we need patients to be diagnosed prior to any dent being made in HCV prevalence

- currently Aust has reasonable diagnosis rates, but very poor treatment rates

- DAAs offering a new treatment paradigm for HCV by combining effective drugs with minimal SE and short durations

- e.g. Ledipasvir/Sofosbuvir (Gilead) - daily, oral, 12 week program, IFN & RBV free with excellent SVRs (97%) in GT1. Even in Pugh B/C patients, SVR nudging 90%. In the co-infected cohort the results are equally exciting

- Abbvie & Merck also have similar products 

 

We CAN eliminate HCV with:

- FUNDING

- better diagnosis rates 

- access to fibroscan 

- significant increased capacity to treat and uptake 

- employ treatment as prevention 

- make prescribing more accessible (in discussion in AUST) 

- FUNDING!!

 

Exciting to think that Australia looks to be leading the way!

The Global Elimination of Hep C

Professor Edward Gane from Auckland NZ gave a visionary plenary presentation on how we may be able to eradicate hepatitis C.

Background on the Hepatitis C epidemic

Global infected population consists of 80-100 million people, with about 250,000 people in Australia

The global mortality attributable to liver disease has increased 60% since 1990, making it one of the fastest rising causes of mortality. Most of this can be explained from liver cancer and cirrhosis due to hepatitis C.

Can vaccination eradicate hepatitis C?

There are many barriers to the successful development of a HCV vaccine:

1. HCV factors:

  • HCV genomic diversity
  • T cell exhaustion
  • Impaired DC maturation
  • HCV NS3/5A inhibits IFN

2. Patient factors:

  • Host genomic diversity
  • Aging population
  • HIV co-infection

3. Other factors:

  • The chimp is the only animal model for vaccine development
  • Preclinical results do not translate to humans
  • With new highly effective treatment, there is reduced interest in vaccine development

Can public health interventions eraticate hepatitis C?

Harm reduction strategies (needle exchange, opioid substitution programs) are moderately effective, modelling has shown that these strategies will reduce HCV prevalence in PWID by a maximum of 30% over 10 years. This is insufficient to eradicate HCV. These strategies do have other benefits, such as reductions in HIV transmission, reductions in crime and increased engagement with healthcare providers. 

Can treatment eradicate hepatitis C?

 b2ap3_thumbnail_IMG_0703.JPG

This slide demonstrates the current hepatitis C treatment cascade on the left, where about 1% of people living with hepatitis C achieve cure/SVR. If we only improve treatment with newly developed drugs, then cure rate will increase to 1.8% (middle cascade). Significantly driving up cure rates to 80% requires that 90% of people living with hepatitis C need to be diagnosed, and 90% of those diagnosed need to take up treatment.

I would think that with access to well-tolerated and highly effective hepatitis C treatment, there will be an increased drive for clinicians to test at-risk patients for hepatitis C, and there will be increased uptake of hepatitis C treatment by those who have been infected.

In Australia we are on the cusp of possibly being able to achieve a ramp-up in hepatitis C management, as the Pharmaceutical Benefits Advisory Committee (PBAC) has recommended the listing of several new hepatitis C treatments (see slide below) AND have recommended that these be available for treating people at any stage of liver disease AND that these treatments can be prescribed by general practitioners in the community, thus allowing for a large-scale rollout of hepatitis C treatment, potentially setting the scene for eradication of hepatitis C.

b2ap3_thumbnail_IMG_0720.JPG

Great session on the HIV Treatment Cascade and moving towards the elimination of 

HIV in New South Wales.

The HIV cascade: a review of methodology and data sources

Nick Medland from Melbourne sexual health reminded us of the components of the HIV treatment cascade and importance of measuring those components.

He said that the cascade should be able to allow comparisons over time, place and sub populations.  

He reported on the review of published and unpublished cascades in March 2015 - found 13 cascades. The differences in the methodology and data sources of the cascades limited comparison.

Dr Kerry Chant, Chief Health Officer, NSW Health

Dr Chant reported on working toward virtual elimination of HIV in new by 2010.

Test more, treat early and prevent are the targets.

She said that the principles underpinning their work are building on strong partnership and strong community involvement. She also acknowledged the work of community partners such as ACON.

She highlighted the importance of real time monitoring and quarterly reporting, in order to be responsive. She presented NSW HIV testing data - showing sustained year on year testing increases, and reported on new HIV diagnoses up to June 2015 - noting a drop in MSM notifications.

What NSW is doing

Promoting HIV testing and making it easier to have a test.

Looking at reducing missed screening opportunities - eg Emergency Departments and General Practitioners

Support ART update - a lot of community mobilisation.

Prevention - condoms and PrEP

Revision of NSW Sexual Health Strategy involves 

Improving access to PrEP

Improving contact tracing for contacts of HIV

Supporting HIV testing in general practice as GPs are important case finders

Early treatment uptake

Ensure people living with HIV are linked and retained in care

Dr Chant concluded by stating the importance of the States and Territories working with clinicians; Knowing each State's epidemiology; and importance of better data by more investment in data collection. 

Tagged in: HIVAIDS2015

This question continues to be a vexing one with our definitive answers coming in probably 5 years time.  There is increasing evidence that AIN3 is a precursor to anal cancer but the problem is that we can screen for AIN3 (anal cytology, high resolution anoscopy) BUT we don't know two fundamental pieces of information.

1)  How do we treat AIN3 effectively?  To date, we have seen many treatment modalities trialed but AIN 3 is highly recurrent.  A triple arm trial in 146 HIV+ MSM reported by Dr. De Vries examined a group of HIV+ MSM who were screened by high resolution anoscopy and histopathologically confirmed to have AIN.  He then randomized them into 3 groups (16 weeks of imiquimod, 16 weeks of 5-FU or 16 weeks of monthly electrocautery).  It was disappointing to see that recurrence rates were high for all patients at 72 weeks (67%), imiquimod users (72%), 5FU users (58%) and electrocautery (68%).  When stratified by perianal vs. intraanal lesions, the peri-anal lesions did better.  

2)  Which men with AIN 3 should we treat?  As Dr. Mary Poynthn from the SPANC team demonstrated, nearly half of HIV+ MSM had detectable high-grad SIL (HSIL) and there was a high regression rate for AIN3 (~39 per 100 person years).  These figures almost match the "success rates" of many treatment modalities.  We need better tools to distinguish the AIN3 that are more likely to progress onto anal cancer (e.g. use of biomarkers like E6/7?).

Until the above 2 questions are answered, I would not suggest implementation of anal cancer screening using anal cytology/HRA.  The alternative is to undergo tertiary screening (i.e. early cancer detection) through regular DARE for those at highest risk (HIV+ MSM who have 100 times greater incidence rates compared to the general population) until more evidence is established for anal cancer screening.

Tagged in: HIVAIDS2015

I attended the panel discussion titled ‘Find Me, Treat me, PrEP me, Heal me’ this afternoon.

The panel members were:

  • Prof Robert Grant,
  • Prof Mike Cohen,
  • Prof  Brian Gazzard,
  • A/Prof Edwina Wright,
  • Dr Mark Bloch,
  • Nicholas Parkhill,
  • Prof Sharon Lewin,
  • Nick Holas
  • Simon Ruth

Some interesting discussion evolved around PrEP, including the recent evidence of decreased condom use, seen at the three month follow up of VicPrEP participants (presented by John de Wit today).

Prof Mike Cohen posed the question of whether reduced condom use, leading to increased rates of STIs (which may increase the risk of getting HIV due to genital inflammation) may reduce the effectiveness of PrEP.

Prof Robert Grant pointed out that participants of recent studies such as the PROUD and iPrEx OLE studies, had high rates of STIs and PrEP was still effective in these cohorts.

One interesting point made by Dr Mark Bloch was that the patients receiving PrEP are followed up every three months for PrEP scripts. This may facilitate adherence to the recommended three monthly STI screen.

Lastly, there was discussion about when newer PrEP agents will become available. Prof Robert Grant advised that a long-acting injectable PrEP agent is just completing Phase 2 clinical trials.

Overall, an entertaining session with some food for thought.

Tagged in: HIVAIDS2015

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