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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Professor Rebecca Guy from the Kirby Institute delivered a talk on how new technologies are important for STI prevention. Media technologies allow young people to 24-hour access to information on sexual health. Computer assisted survey instrument (CASI) is an efficient way for clinics to collect information and triage clients. It is acceptable to both patients and clinicians. Studies have found women are more likely to report higher numbers of male partners via CASI than during a face to face consult with a clinician.

ACCEPt is a prevalence study, which aims to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing among 16–29 year olds in the general practice setting. Findings from the study include: 73% of chlamydia cases in the study were asymptomatic patients attending for non-sexual health reasons. This highlights the importance of offering all young people chlamydia treatment at GP visits. 

Point of care testing (POCT) in rural areas has been successful. POCT can significantly reduce the time from diagnosis to treatment in many clients-especially marginalised populations who are often transient.

 Professor Mark Hayter from the University of Hull spoke about integrated sexual health services and highlighted the need for school based sexual health clinics. There is some evidence to show a reduction in births to teenage mothers and a reduction in chlamydia rates among young men in young people who have access to school based sexual health clinics.

More focus is needed on alcohol misuse interventions and services. Alcohol consumption can reduce inhibitions and can lead to unsafe sexual practices. Clinicians should include alcohol and drug history as well as the patients sexual health history and provide brief interventions and referrals to appropriate services as needed.

It was also highlighted that whilst PrEP is very important for HIV prevention we also need to counsel men around safe drug use when they engage in “chemsex” as this can pose further r

 Christopher Fairley postulated that pharyngeal gonorrhoea could be transmitted by saliva-via deep kissing and by using saliva as lubricant; which stirred great interest among the attendees in this morning’s session.  Anti-bacterial mouthwashes may be the way forward in substantially reducing gonorrhoea prevalence. Watch this space!

 Catriona Bradshaw discussed Mycoplasma genitalium (MG) and Chlamydia trachomatis (CT) infections in the rectum. There is no standardised treatment for rectal chlamydia. The Centre for Disease Control guidelines does not distinguish between urogenital and rectal chlamydia.

Doxycycline appears to be the best treatment for rectal chlamydia. A randomised control trial is underway and this will inform treatment guidelines for rectal chlamydia.

MG has been less studied that CT and the data available on rectal MG is limited. MG testing is unavailable in many settings and may take 2 or more weeks to get a result.

There have cases of macrolide resistance, which have meant that this clever bacterium may need dual antibiotic therapy to treat and there is a great need for more antibiotics to be developed.

Key messages

-Doxycycline should be used over azithromycin for rectal chlamydia while awaiting RCT evidence

-Rectal MG is commonly asymptomatic and more common in HIV positive males

-MG is predominantly macrolide resistant

-Better treatment guidelines and treatments are needed

 Jane Tomnay- Patient-delivered partner therapy for STIs: the current state of play in Australia

Patient delivered partner therapy (PDPT) describes the practice in which treatment is prescribed for the sexual partner/s of an index patient diagnosed with a sexually transmissible infection, as well as the index patient. The patient then delivers a prescription, or the treatment, to their partner/s. PDPT aims to target those partners who are unwilling, unlikely or unable to consult a health professional in a timely manner.

Jane presented about the difference between a ‘provider referral’ versus ‘patient referral’ for the treatment of STIs. PDPT can be less resource intensive and was found to be acceptable to many. PDPT is already happening in Australia and the NT has taken the lead with this initiative.

Key messages

-PDPT works

-PDPT for chlamydia using azithromycin is safe

-Pharmacist’s knowledge regarding PDPT was low therefore education is needed

-In trials there has been no difference in partners followed up between medication PDPT and prescription PDPT

 

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The Conference opened with a broad based plenary looking at the new landscape in HIV, often referred to as the HIV Testing 101 Workshop. This is a two hour session which will be on line shortly and really is an excellent overview. It starts out with a glossary of terms and then moves through technology; performance; programs; surveillance and the relationship between laboratory and strategy.

I strongly recommend that anyone setting out into the world of testing watch this session. The slides will all be up on the website some time after the conference and we will advise when this happens.

The USA has recently introduced a change algorithm for HIV diagnostic testing. This raises practical issues for laboratories. But an equally important issue for this conference is how laboratories support initiatives to increase testing (and timeliness of testing) and improve the care continuum.

Details can be found on the website http://hivtestingconference.org  

Key HIV Testing Issues

Key issues in this meeting are how to get testing done early enough and also how to use the best test on an early-after-exposure sample. This will likely play out over the next few days. Clearly the cognitive distance between the laboratory and the clinic is narrowing here. Labs are trying to play a role in the clinical improvements that are sought in reducing the time between exposure and testing. Yet with the increase of self testing, and large scale community clinics with the capacity to perform more complex tests, the laboratory is coming much closer to the community.

With this comes the big question for me: How does one get this information to the person needing testing, at the time that they need it? The Achilles heal in any algorithm would seem to be the differentiation of the population upon which it is performed.

Joanne Stekler (Seattle) discussed this in the breakfast session today. Indicating that the greatest variation between yield on different tests is how differentiated the sample is.  Population-based screening is low yield in low prevalence settings and yield rises dramatically when more targeted testing is performed.

Increased infectivity during seroconversion and early in infection mean it is vitally important to get people to test during this period. Though this has not been discussed here yet, the role of PEP in this context should be reconsidered.

 

Day 2 of IAS2015, I attended a very full lunch poster discussion session entitled HIV Testing: The Gateway for Everything.

Sheri Lippman presented two posters. The first presented results from a cluster randomized controlled trial comparing the ‘one man can’ campaign in South Africa which aimed to engage men into testing through community mobilization. Community mobilization was found to be associated with higher testing uptake, though not equally for all CM domains. The main three domains which had the greatest impact were consciousness, concerns and collective action.

Sheri’s second presentation was on a pilot study examining feasibility and acceptability of self-testing in transgender women in San Francisco. 50 HIV-ve trans women were provided home HIV test kits and asked to utilized the tests once a month for three months, behavioral data was also collected at baseline and three months. 96% of study cohort had multiple recent partnerships and 80% had engaged in sex work, so as with other transgender communities, a pretty high risk population. Most found the test easy to use and would recommend to their friends (>90%), 68% would use the test again. The main reasons provided for not using again were around gaining access to counseling services that facility-based testing provided, and most participants had tested with a partner or a friend. A marketing strategy which provided two home-based tests aimed at testing with a partner could be an efficacious method for targeting this hard-to-reach population.

Laura Derksen from the London School of Economics presenting results from a cluster-randomized trial examining methods to reduce stigma in a community based setting in Malawi. 122 Malawi villages were targeting (60 intervention villages and 62 control) which reach two thirds of the target 15-49yrold population. In the control villages information was provided on the benefits of ARV including prolonging life and reversal of AIDS. While in the intervention villages, in addition to the control information, information regarding reduced likelihood of transmission in partnerships where the HIV+ve partner properly adhered to ARV was also propagated. The overall concept being that if they could reduce stigma, by showing that individuals who tested were in fact safer sexual partners then rates of testing would improve. The percent of the population having testing for HIV post-exposure was found to be  60% higher in the intervention arm compared to the control arm, and this was consistent for both genders.

Perhaps the most relevant to the Australian setting was a poster presented by David Katz, which examined self-testing as a method to increase overall testing frequency among high-risk MSM in Seattle. 230 HIV-ve MSM were randomized to have access to free HIV self-tests versus standard HIV testing for 15 months. The primary endpoint was the comparison of HIV testing frequency, secondary endpoints included non-inferiority in regards to behavioral markers of HIV risk acquisition. The mean number of test in the self-testing arm was 5.3 (4.7-6.0) compared to 3.6 (3.2-4.0) in the control arm, which was statistically significant (p<0.0001). Non-inferiority bounds were met for risk acquisition, which included difference in frequency of bacterial STI diagnosis at 15 months, likelihood of non-concordant anal intercourse at 3 months, and number of male non-concordant partners. However confidence intervals were wide for the secondary endpoints and the study not really adequately power to examine these associations.  

And finally the last two posters were presented by Sue Napierala Mavedzenge and Pius Tih Muffih respectively. Sue presented results of a feasibility study which examined the reliability of self-testing in both rural and urban settings in Zimbabwe. There was high sensitivity and specificity of interpreting self-test kits in both rural and urban settings, however slightly lower sensitivity in the rural setting, which was likely a result of lower literacy in this group. Some practical issues to encourage interpretation of the test (such as increased window size) were discussed.  Pius Tih Muffih provided the results of a very interesting study which examined integrating partner notification into Option B+ in Cameroon. Results looked promising with 823 women testing positive providing information on 840 partners of which 693 were notified, of whom 421 were tested for HIV and 139 new HIV+ve cases identified and linked to care. They had not observed any backlash in terms of violence to women as a result of the notification but this was highlighted as an issue which needs to be carefully monitored.

 

 

 

 

 

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

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