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 STI

Why are some common STI's neglected over others? 

Gwenda Hughes from the Centre for Infectious Disease Surveillance and Control at Public Health UK spoke about the surveillance of neglected STI's this morning. 

On average every year, there are around 358 million new infections of four curable STI's, which one do you think is the highest number?

Syphilis, Chlamydia, Gonorrhoea, or Trichomoniasis?

6.6 Million Syphillis infections, 78 Million Gonorrhoea, 131 Million Chlamydia and at the highest; 143 million Trichomoniasis.

Caused by the parasite Trichomonas vaginalis, it is nine times more prevalent in women and with the associated risk factors of lower socio economic factors, lower levels of education and increased number of partners.

With poor specificity on wet smears, limited surveillance data, and knowledge gaps in racial ethnic disparity target groups, this is an STI that would benefit further research. 

In Sydney we do see limited infections, and this is more common in rural Australian settings, and higher amount in Aboriginal Torres Strait Islanders. 

Lymphogranuloma Venerum  (LGV) - is commonly tested in Australia with positive rectal CT infections, but one point I thought was interesting the presentation was in Germany that out of 154 MSM with positive CT infection not only had 17% had LGV rectally, but 15% had pharyngeal LGV.

Would this number be similar in Australia with the Sydney study (David Templeton) showing 3 out of 75 positive LGV with rectal CT. 

Could we do pharyngeal LGV testing with positive CT Pharyngeal PCR swabs?

WHO STI Treatment Guidelines 2017

 

Good morning from the 2017 HIV/STI Conference in Rio De Janeiro. There may be a cross over in some topics with other ASHM bloggers but over the course of the congress we will be blogging about different items.

This morning commenced with WHO treatment updates and guidelines, which had not been updated since 2003. The WHO updated guidelines and their objectives focused on ensuring they have international guidelines for the effective treatment of Neisseria Gonorrhoea, Chlamydia Trachomatis and Syphilis.

The majority of all treatment guidelines have already been adopted by Australian STI Management guidelines (STIPU) and are in place, but the key points taken will be outlined below.

* Neisseria Gonorrhoea (Assoc. Prof. Magnus Unemo - Director Swedish Reference Lab) - Dual Therapy (Ceftriaxone 250mg IMI with Azithromycin 1g Oral) recommended in all cases (Ano-Rectal, Oropharyngeal and Genital), unless resistance to Azithromycin is known, then single therapy with Ceftriaxone 250mg or Cefitixime 400mg can be used but again this only in specific cases and specialist advise should be obtained.
NB: STIPU do recommend 500mg Ceftriaxone IMI as do a number of other clinics worldwide. 

- Reinfection is treated again with dual therapy, but consideration could be given to treat with 500mg Ceftriaxone IMI with 2g Azithromycin Orally.

* Chlamydia Trachomatis (Nicola Low - University of Bern)

Guidelines were again similar to what STIPU guidelines in Australia recommend with a strong enforcement around Doxycycline versus Azithromycin in Ano-Rectal cases.

- 1g Azithromycin oral for Uncomplicated genital infections or Doxycycline 100mg Oral twice daily as alertantive treatment.

- Ano Rectal infections, there was a important point about ensuring Doxycycline 100mg BD for 7 days was used as first line treatment, and that Azithromcyin not be used as a treatment option. 

- For LGV, Doxycycline 100mg BD for 21 days is now recommended treatment versus the previous 14 x day treatment. 

- An important change from the 2003 guidelines was that Erythromycin was considered first line treatment in pregnancy, but now Azithromycin is the recommended treatment for women with a Chalmydia infection during pregnancy.

It should also be noted that Nicola Low mentioned there was not enough evidence for Azitrhomycin extra dosing to be used to treat Ano-Rectal Chlamydia as previously done for patients who might have had issues with Doxycline dosing adherence.

Treponema Pallidum (Syphilis) - Dr. Francis Ndowa (Zimbabwe).

Australian STIPU guidelines already reflect current guidelines.

- Early Syphilis -  2.4million units (1.8g) Benazthine Penicillin IMI as a single dose is still recommended as first line treatment or Doxycyclinne oral 100mg BD for 14 x days if there is a Penicillin allergy. 
(NB: Numerous other alternatives given, but not enough information was transcribed to write about)

- Late Syhpilis (>2 years) - 1.8g Benzathine Penicillin IMI as three doses spilt into 3 x weeks (i.e.: Every seven days), which is current to Australian guidelines. 

Genital Herpes Simplex Virus (HSV) - Prof. David Lewis - (Australia).

19.2 million new HSV2 diagnoses in 2012 for people aged 15-49 (11.3% Global prevalence)

6 x recomendations which show commence treatment straight away on first initial episode. Evidence showed a reduction in symptoms 2-4 days less than placebo and HSV shedding in 9.2 days
NB: See Brett Hadlow's blog for information around medication dosage recommendations).

For cases under four occurrences a year, treatment again is recommended with a 2.5 day reduction in viral shedding.

For cases over four reoccurrences, repressive therapy is recommended over suppressive and a twice daily dose of Acyclovir (400mg) or 500mg Valaciclovir once daily. Evidence showed less frequent HSV occurrence, and reduced shedding.

Overall it was good to see Australia is working within the WHO guidelines to combat STI prevention and ensure appropriate treatment.

For current Australian STI Guidelines, please see http://www.sti.guidelines.org.au

Photo 1: Blogging in my hotel room with Brett Hadlow looking over Barra Da Tijuca Beach.

b2ap3_thumbnail_IMG_0172.JPGb2ap3_thumbnail_IMG_0164.JPG

0 0 1 676 3855 laura cunningham 32 9 4522 14.0

Normal 0 false false false EN-AU JA X-NONE

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

 

0 0 1 676 3855 laura cunningham 32 9 4522 14.0

 

Normal 0 false false false EN-AU JA X-NONE

 

 

 

 

 

Monday 14/11/16 – Day 1: Jan Edwards Trainee Session

Dr Danae Kent, Senior Registrar at Adelaide’s Clinic 275: ‘Testing for Rectal Chlamydia in Women – Is It Worth It?’

In short the answer was yes…and no! 

Rectal chlamydia infections in women have the potential to result in significant morbidity and enhanced HIV transmission. 

Few other Australian studies have looked at this topic.  The estimated rectal CT positivity rate in women is 5-27% (variable depending on population eg. higher in sex workers and sexually adventurous females).  Awareness of site of CT infection is important as this has implications for choice of treatment (rectal CT treated with Doxycycline vs genital CT treated with Azithromycin).

Method:

This South Australian retrospective study looked at women who received anal CT testing if they reported anal sex and/or anal symptoms.

Results:

Overall CT positivity rate = 8.5%

Young women less likely to have anal CT testing done but more likely to have positive anal CT result (of those with a CT positive result, 16% of women <20yrs were positive for anal CT)

Isolated rectal infections:

70% were found to have urogenital AND anal CT

19% were found to have rectal CT only

11% were found to have urogenital CT only

Therefore urogenital testing alone would miss 1 in every 5 cases of chlamydia confirming the value of testing for anal CT where a women reports anal sex and/or anal symptoms.  These findings are not generalizable to settings outside the sexual health clinic. 

Interesting food for thought and also a timely reminder of the importance of a thorough sexual history for the female client including enquiry about anal sex practices.

 

STI screening in the context of PrEP

Wednesday 23rd Feb Session TD-12

It’s Complicated: Renal Function and STIs in PrEP Users.

STI Data From Community-Based PrEP: Implementation Suggest Changes to CDC Guidelines.

Presenter: Sarit A Golub (NY, USA). Oral abstract an Poster.

 

Main findings of a review of STI screening in the context of PrEP;

Current CDC guidelines recommend screening at 6/12 intervals or earlier only if symptomatic.

They decided to screen all PrEP attendees routinely regardless of symptoms at 3/12 intervals.

They found that 77% of STIs would have been missed if they weren’t screened at the 3/12 routinely because of reporting as asymptomatic.

STIs screened were; Gc, CT, RPR in urethral and rectal samples. Pharyngeal testing was also done but not included in this study. The majority of PrEP attendees were between 22-40yrs of age.

Test of cure was only conducted on those that were documented as not having received first line therapy at the time of initial diagnosis. Current treatment for rectal CT was 1g Azithromycin, but 7 days Doxycycline was offered if TOC was +ve.

The researchers have also proposed a theory for why there was a spike in STI detection at 6/12. Anecdotal only, but PrEP attendees reported increased sexual risk activities after the 3 month initial HIV screen had come back negative, so they could actually believe that PrEP was effective for them.

Overall they are recommending that in light of many new PrEP guidelines and protocols being developed that STI screening of MSM on PrEP should be 3/12 regardless of symptoms.

 

These recommendations are in fact consistent with our current STIGMA guidelines for MSM screening that suggest testing up to 4 times per year.

http://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf

Something additional to consider is that should and if PrEP be prescribed by any clinician, without S100 authority, then there may be a need for some re-education into promoting sexual health screening especially in the community general practice setting. 

Tagged in: CROI2016 PREP STI