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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Christian Callebaut, Clinical Virology, Gilead USA, presented the findings of their clinical trial GS-US-292-0119.

Virologically suppressed, treatment-experienced patients on complex multi-tablet regimens were randomised to either switch to a simpler, more convenient antiretroviral regimen or remain on their current optimised ART.

After 48 weeks:

  • The regimen consisting of E/C/F/TAF DRV demonstrated maintained viral suppression in 94.4% of patients.
  • In the DRV-containing “Stay on Baseline Regimen” arm, maintained viral suppression was 76.1%

All patients had documented resistance to 2 classes of antiretroviral (ARV) agents at baseline. Detailed ARV regimens and the resistance profile of the study population are described.

Study methods:

The Stanford HIVdb algorithm version 8.01 was used to calculate genotypic susceptibility scores (GSS).

For each drug, a 5-point scale was used:

  • Susceptible = 1
  • Potential low-level resistance = 0.75
  • Low-level resistance = 0.5
  • Intermediate-level resistance = 0.25
  • High-level resistance = 0

 The total GSS for a given regimen was calculated as the sum of the scores for each individual drug. 

Results:

A total of 94.8% had documented resistance to 2 classes of ARVs, including:

  • protease inhibitors: 34.8%
  • non-nucleoside RT inhibitors: 88.1% and
  • NRTIs 94.8%.

The most common resistance associated mutations (RAMs) were:

  • Protease Inhibitor RAMs: L90M (15.6%) and V82A/F/L/S/T (14.8%).
  • NNRTI-RAMs: K103N/S (63%) and Y181C/I/V (19.3%) and
  • NRTI-RAMs: M184V/I (83%) and K65R (23.7%).

Thymidine analog mutations (TAMs) were present in 42.2% of patients (59.6% with one or two TAMs and 40.4% with three TAMs). 

The distribution of GSS at study entry was similar across treatment groups.

Patients in the E/C/F/TAF DRV arm maintained virologic suppression similarly, regardless of the DRV dosage received before switching (33/33 and 51/56 with treatment success in the 600 mg BID and 800 mg QD groups, respectively).

In the E/C/F/TAF DRV arm,

  • 11/89 patients (12.4%) had GSS <2,
  • 51/89 patients (57.3%) had GSS ≥2 and <3, and
  • 27/89 patients (30.3%) had GSS ≥3.

Within each treatment group, patients maintained virologic suppression similarly regardless of their GSS at study entry.
 

Conclusions:

  • Despite the high incidence of pre-existing resistance in this population, including resistance to ≥2 classes of ARV agents and presence of K65R or ≤3 TAMs, strategic simplification to E/C/F/TAF DRV was statistically superior to staying on the baseline regimen.
  • Patients benefited from switching regimen regardless of their prior DRV dose and their GSS.
  • Treatment with E/C/F/TAF DRV offers a simpler and more convenient option for treatment-experienced patients on complex multi-tablet regimens.

Details of the study can be found here: https://clinicaltrials.gov/ct2/show/study/NCT01968551

 

 

 

 

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.

 

This WHO consultation followed on immediately from the CDC. This was one of the data collection workshops aimed at feeding into the development of the new WHO resistance testing guidelines. I was the only person in the audience from South East Asia and the Western Pacific. But a survey can be completed on line Insert website.

 

What was important here is the trade-off between affordable therapy for most people versus switching (and abandoning 1st line therapy). Willem Venter, from South Africa, cautioned against switching, and introduced the practicality that this would not be affordable, if 85% of people were benefiting from that therapy. Jonathan Shapiro questioned the 15% versus 85% assumption about resistance, and suggested there might need to be more consideration of this.

I raised the issue that there was no-one in the audience from ESA and the Pacific, including Australia. The consultation is open online and I was told consultation would come from the WPRO and SEPRO offices.

 

http://www.who.int/hiv/topics/drugresistance/en/ 

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25th HIV Drug Resistance Workshop

This is the second time I have attended this meeting. It was very different from last year. Considerable attention was paid to transmitted resistance in the context of PrEP. While this does occur, it does not appear to be persistent.

There were also a number of papers looking at the practical implications of resistance in treatment. A number of presenters reported that resistance may not render a regimen defective. There was discussion about the utility of testing and while resistance testing remains too costly for use in many settings, it was also suggested that many clinicians in developed settings perform resistance testing, but don’t use it in regimen selection. There was some suggestion that resistance testing is becoming less important in the context of newer therapies. One take home message was that the longer people are on treatment, the greater the likelihood to resistance.

Preserving 2nd and subsequent line therapy was seen as the major reasons for not switching, even in the absence of resistance testing, particularly in low and middle income settings.

 

Sequencing virus for epidemiological purposes is becoming increasingly important. A number of papers looked at clusters. It was suggested that some virus may be becoming more durable. With 30 clusters in one sample accounting for 1500 infections, while 1300 infections were seen as singleton transmissions. In this study the resistant virus was seen to be as fit as wild type virus. At a practical level what this means a new population is getting infected with lower sexual activity and with a lower testing frequency. There was also an interesting paper looking at clusters among injectors. The abstracts can all be found on line at https://www.informedhorizons.com/resistance2015/pdf/RW2015_Book.pdf