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.

Subscribe to this list via RSS Blog posts tagged in PrEP access

Day 1: Afternoon Session

Welcome back to the afternoon (evening really, my laptop ran out of juice). In case you were wondering, it did eventually stop raining. Also, apologies for the formatting error in my last post, I'm sorry you had to see that.

The afternoon session in the main theatre was PrEP and was fascinating. I chose share with you the EPIC-NSW analysis done by Associate Professor Rebecca Guy from the Kirby Institute at UNSW.

Quickly a bit of information for those not from NSW or familiar with this program. Expanded PrEP Implementation in Communities in New South Wales (EPIC-NSW) is a study commenced in March 2016 and was designed to provide free access to PrEP to people at high-risk of HIV infection for free. This is the result of an active partnership between NSW Health, the Kirby Institute, ACON and clinical services involved in the study. The study was planned to have a rapid rollout and high clinical coverage within target populations and now has enrolled over 7,500 participants.

Rebecca spoke to the study, highlighting the similarities and disparities in demographics of people enrolled in the study and with data for new HIV notifications in MSM. The data for HIV notifications was taken from 2015 and the EPIC-NSW data up to and including September 2017.

Rebecca told us how the data shows mostly similarity in the capture of population at risk within the age, locality (urban vs. regional and remote) and to a somewhat lesser degree people identifying as Aboriginal or Torres Straight Islander (ATSI). However the one area demonstrated to have a disparity between the data and HIV notifications is that of people born overseas. Rebecca’s analysis has shown that in particular, people born in South East Asia (SEA) and North East Asia (NEA) are not reflected within the EPIC-NSW enrolments. From the data above, the rate of HIV notifications for persons born in NEA or SEA are 2.5 and 2.4 times respectively compared to the numbers reflected within the EPIC-NSW data.

In 2017 ACON increased the number of culturally appropriate programs, advertisements and information was released, targeting these populations. Examples such as posters in other languages and programs and information targeted to particular language groups has coincided with a marked increase in the population reflected within the study.

Rebecca concluded that although we mostly have participation that reflects the population targeted, we still have work to be done in order to reach the goals of the EPIC-NSW study.

Through my position in a sexual health clinic, I have been involved with this study, although I am well and truly at the lower end of the food chain than Rebecca. It is worth recognising the impacts on changing information available and making culturally appropriate services available to engage an under represented population. This is a great example of how changes in strategy can have a significant effect, although as Rebecca said, there is more work to be done.

I will be back tomorrow and hopefully won't be writing so late, I am now more prepared for batteries running out mid session. See you tomorrow!

 

Just after lunch I attended a session chaired by Gus Cairns, an HIV activist from the UK who spoke passionately about the need for PrEP in Eastern Europe earlier in the conference. A few speakers provided their thoughts on what might be holding things up with PrEP:

 

Justyna Rowalska from Poland presented HIV practitioners perspectives on PrEP in East, Central and South-Eastern Europe, the findings of a survey of many clinicians about PrEP. The findings concluded that the main obstacle to prescribing is not being covered or paid by public health, and that there was no official medical approval for the medication in many countries yet. She stated most said they would prescribe it if it was approved, but that clinicians needed guidelines in their countries, wanted a government strategy that includes PrEP and off label approval.

Gennady Roshchupkin from Georgia then presented Georgia’s PrEP demonstration project that has recently commenced with 100 places in 2017 and a further 100 in 2018, funded by the Global Fund but proposed his concern about what will happen when/if the Global Fund revokes funding. He suggested that the logical solution would be to involve some local NGO’s but that they were used to deal with people in crisis, and PrEP isn’t really a crisis. He thinks co-payment schemes and de-medicalising the delivery of PrEP may also keep costs down.

The panel then commenced discussions. Italy’s comments are of note: Italy has no reimbursement for PrEP and most are sourcing over the internet. The panellist (I have not recorded his name, apologies) stated that the discussion should no longer be medical or scientific, it works, and medical staff need to start advocating for MSM and working with MSM if they are ever going to reach the 90 90 90 targets by 2020.

I saw many other presentations today which will be blogged about by my fellow ASHM scholarship recipients, all of which have been equally as thought provoking and my brain is ticking over with ideas to bring home to Clinic 275. Witnessing the European perspective has been really enlightening.

 

I’m very grateful to ASHM for the opportunity to attend this wonderful international event and strongly encourage other nurses to apply for scholarships in the future– sure, a bit of the science that was over my head but there was still plenty of research that I could sink my teeth into and learn a lot from. Buona sera from Milan, Emma

Next up for me today was the Epidemiological challenges of HIV surveillance presented by Anastasia Pharris.European Centre for Disease Prevention and Control (ECDC) in Stockholm, Sweden  Anastasia showed data highlighting the contrast in reported routes of HIV transmission by European sub-regions in 2015 across the West, Centre and East.  Heterosexual transmission accounting for a significant portion across all areas, injecting drug use significantly more in the East and MSM transmission more in the west and centre.  She demonstrated that sex between men is significantly underreported and stigma and discrimination is still a huge barrier. Anastasia commented that Europe is lagging behind in its response to the HIV epidemic and it is not on track to reach the 2020 targets.  She highlighted there are some issues urgently still needing to be tackled, one in particular is the development of policy to include undocumented migrants which account for a proportion of the late presentations and also community viral load which has public health implication.  Finally she talked about more wide scale role out of some successful models such as community based testing, home sampling, PrEP scale up, harm reduction efforts such as needle syringe programmes and opiate substitution programmes and reduction of stigma.

 

Following on from the breakfast buffet of the bright future for ART and European epidemiology I moved on to the Industry sponsored degustation menu of case studies entitled “Seeing the whole picture” presented by Giovanni Di Perri, Professor of Infectious Diseases at the University of Turin, Italy  & Jürgen Rockstroh, Professor of Medicine and Head of the HIV Outpatient Clinic at the University of Bonn in Germany and a panel of experts. 

 

Giovanni Di Perri opened the session discussing the prevention of harm in patients with HIV and detailed the common comorbidities associated with HIV and the impact of long term ART such as neurological impairments, cancer, CVD, Bone disease, liver and kidney disease. He highlights the need to carefully manage our patients as a whole, going beyond undetectable, to improve their overall health by considering comorbidities (prevent and treat), counselling our patients on lifestyle risk factors and careful selection of ARTs that balance HIV efficacy, durability and toxicity.  3 case studies were then presented by panel members focusing on differing disease burdens such as bone density, renal function, and prevention in the healthy client with lifestyle factors such as smoking.  Audience participation was required for responses on care priorities, comorbidity treatment options, ART switches and perhaps the one with the most diverse spread of results was in answer to the question when to start ART treatment in the case of a 23yr old MSM diagnosed with HIV that day.  40.4% of the audience said ‘immediately (today)’, 43.8% said ‘once all baseline data were available’, 1.1% answered ‘CD4<500’, 1.7% said ‘Wait, this patient is too young to start lifelong therapy’, and 12.9% said ‘Wait – I need to assess whether this patient will be adherent’.  In this panel discussion reference was made to the San Francisco experience of same-day observed ART initiation versus standard of care and its benefits to viral suppression.  Overall feeling from the panel was a slightly more cautious approach to treatment initiation where one awaits resistance profiling and other baseline assessments before commencing ART to allow for adequate characterisation of any co-morbidities and also time to spend with the client getting to understand their wishes, likely adherence and willingness to start therapy.

 

And so concludes the second day of yet more mouthwatering (or rather thought provoking) messages and i look forward once again to more palate pleasers tomorrow! 

 

 

The Round table meeting made some interesting points concerning the recent instigation of PrEP in the UK and France.

 

 Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot, France) showed that daily and on demand PrEP is cost effective for the community. More importantly it has helped take the fear of sexual activity and anxiety from a population that are over represented  when it comes to mental health care issues. He felt that PrEP is still not reaching high risk groups such as  young MSM, migrants and the trans population. Young MSM are a particular problem  in that they often feel stigmatized about their sexuality and unwilling to  engage with the medical profession. They may also be in some denial about their HIV risks and are a difficult population to ensure compliance with medication. Social media apps eg Grindr, Hornet and Planet Romeo are very important  resources for HIV ,PrEP and PEP education.

 

PROUD and IPERGAY studies have confirmed the effectiveness of daily and intermittent/ on demand Truvada.(4 tabs). Maraviroc was not shown to be an effective PrEP agent. Current studies with TAF/FTC are promising as is injectable Cabotegravir LA. Topical drugs such as vaginal gels also have an important place. The possibility of future over the counter PrEP raised some concern by the panel who felt  medical intervention is needed at some point in the PrEP pathway.

 

Emma Devitt from the Dean Street Clinic Soho, UK showed some impressive rates of decline in new HIV diagnoses in the last year. She felt this was due to a combination of factors their clinic offers including:

-frequent screening for HIV 

-rapid ART instigation for HIV positive people

-regular STI screening and rapid Rx of STI

-use of PEP and now PrEP

 

A very informative and topical meeting  from some incredibly dedicated and progressive doctors.

 

also see blogs from Rebecca Houghton and Emma Clements on this topic

Tagged in: EACS 2017 PrEP access

This was an interesting oral abstract session regarding community knowledge and approaches to pre-exposure prophylaxis.  PrEP was discussed in detail and covered topics like barriers to uptake of PrEP, preferences for prevention technologies, measuring adherence in PrEP users and how the health system and study designs of PrEP trials can facilitate rapid enrolment of those at high risk of HIV acquisition.

The first speaker was Adeline Bernier from France.  Although PrEP is already available in Norway and France through government subsidised programmes it has not been widely taken up in the rest of Europe.  She presented results from The Flash! PrEP in Europe (FPIE) online survey.  This was a community-based research study aiming to assess interest in and barriers to PrEP uptake amongst respondents from 11 European countries.  They found low knowledge of PrEP amongst at-risk groups, high interest in PrEP but low uptake.  Most commonly cited barrier to taking PrEP was fear of side effects.

Darrell Tan presented results from an MSM survey conducted with those undergoing routine HIV testing.  They asked questions regarding preferred method of PrEP delivery (oral, injectable, topical) and whether the reliability of different technologies would influence their decision on which method to use.   The results were many and varied.  Further analysis is required to understand what influences each individual’s preference for PrEP.

James Ayieko from Kenya presented results from the ongoing SEARCH trial, 18% of 4,064 participants took up the offer of PrEP within 30 days.  Participants’ perception of own risk did not always match that from a risk score.  This indicates further community-based education regarding risk is required for those considering PrEP.

Edwina Wright presented data from the Melbourne cohort of the PREPX trial. Recruitment to the PrEP trial was facilitated by a high community PrEP awareness and involvement of GPs and Pharmacists who were remunerated for their services.The high PrEP awareness in Australia contributed to the high enrolment of the ongoing PrEP study.

Rupa Patel presented data from a US study which found a good correlation between adherence measured by 3-month MPR (medication possession ratio) and 7-day self-report with TFV-DP (tenofovir diphosphate) blood levels in DBS (dried blood spot) of MSM taking daily oral PrEP.  The good correlation of the 3-month MPR and 7-day self-report with biological measures of adherence in PrEP users suggests that this could be ideal for measuring adherence in the clinic setting.

Hanne Zimmermann from the Netherlands presented data from a longitudinal semi-structured interview in MSM using PrEP.  This revealed that MSM switched between daily and event-driven PrEP use or even stopped PrEP based on their personal situation and risk exposure.  Individuals made decisions on PrEP use based on perception of their own risk.  The authors concluded that in order to successfully support future PrEP users, a tailored approach, addressing choices for PrEP regimens as a continuum of flexible and changeable choices, is essential.  Appropriate education would be an essential part of this strategy.

All things PrEP (courtesy of Prof Jared Baeten)

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

 

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

 

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

 

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

We have just heard from 7 speakers on the status of PrEP across Euro and North America. There is considerable support for PrEP and incredible consistency across the regions in both trends and challenges a s well as interest.

Clearly there is no debate about the efficacy of PrEP, thought there remain differences in choice about daily or on demand PrEP. There seems to be considerable comfort in the level of resistance, side-effects and toxicities, while these may be appearing they are at such low levels as to no impact support for PrEP.

There is also a very generalised concern about cost of PrEP, but a growing confidence that cost issues will be addressed. How to implement PrEP is where the differences are most striking. Many people are indicating that PrEP must be resourced by cutting back in other areas. Cost effectiveness remains linked to the cost of the drug ad the level of risk, but a number of speakers also introduced location or background prevalence into that assessment.

PrEP access, at least in a number of settings, does not match HIV transmission risk. One presenter gave a detailed account of where PrEP is accessed and by whom. Overwhelmingly PrEP access in the USA favours white MSM, yet black and hispanic MSM and women are at much greater risk. This is s strong take home message. We will need to make sure that PrEP can be assessed by at risk populations and communities at greater vulnerability.

 

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