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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The opening plenary talk was given by Dr Valarie Delpech, who outlined the progress towards attaining treatment for all.

 

  • the UNAIDS target for 2020 is 90-90-90
    • 90% of patients diagnosed
    • 90% of patients on ART
    • 90% with viral suppression
  • data from Levi et al (2016) showed
    • 54% diagnosed, 41% on ART and 32% virally suppressed (2015 data)
  • there appears to be a great disparity in the countries able to achieve this with many having poor rates of diagnosis and hence low rates of treatment/viral suppression
  • Dublin declaration data: EU/EEA countries are performing better than the non-EU/EEA
  • to date, no country has met the 90-90-90 goal (except claimed by Sweden)
  • a major issue
    • most countries have very little data about actual rates (even 4 decades into the epidemic)
    • there is variation with data sources and quality of definitions/standard methodology

Dr Laura Waters talk on HIV treatment cascade and other HIV population prevention/treatment issues.

 

2020 goals aiming for 90% of people with HIV diagnosed/90% diagnosed on treatment/90% on treatment undetectable - corresponds to 74% of those with HIV having undetectable viral load.

  •  Currently (globally) only 32% of those with HIV are on treatment with undetectable VL.

 

June 2016 paper (Lazarus et al) on adding a “fourth 90” to the 90-90-90-90 targets; that 90% of those on ARVs with undetectable VL have good health-related quality-of-life. Especially pertinent considering incidence of co-morbidities and ageing HIV-infected population (in developed countries).

 

2016 research from Toronto (Wilton et al) on high-risk populations and perception of risk studied 420 MSM who were objectively high risk:

 

  •       68.3% didn’t perceive themselves to be at moderate to high risk
  •      23.6% unaware of PrEP
  •      40.1% unwilling to use prep
  •    47% lacked a family physician with whom they could discuss HIV issues

 

 

Survey of Glasgow2016 audience on new directions for treatment - 40% of attendees believe that non-oral ART will be first-line by 2026.

 

Transmitted drug resistance by geographical region (START trial) - Australia highest (17.5% had any transmitted drug resistance)

The presentations from the HIV Diagnostics Conference have now been put on line. They are accessible at

http://hivtestingconference.org/2016-hiv-diagnostics-conference/oral-presentations/

You can access the full program from this link and simply click on the desired presentations.

Those who pay much attention to the HIV testing landscape in the USA will be aware that there was a long period where the testing algorithm was debated, discussed and reviewed, resulting in the 'New' algorithm coming into effect in 2014. At this conference it was suggested a number of times that the new algorithm should now be redrafted.

Largely the reason for this is the shift in treatment guidelines and the relationship between testing and treatment. The 'new' guideline was written against a background of selective CD4 and viral load based decisions about when to start treatment. Now, with the emphasis being on starting people on treatment as soon as feasible after diagnosis, the need for repeat testing was questioned. This is an important shift, where one can see treatment and clinical practice driving precursor testing. These issues are discussed in 

Session C: CDC/APHL Laboratory Testing Algorithm and 

Session D: CDC/APHL Laboratory Testing Algorithm (Part 2)

There was a very good round table discussion on Wednesday morning which looked at matching testing approaches to the HIV cascade. Joanne Steckler raised the issue about the large differential between people tested and people lost to follow-up. This comes from work in Washington state, where a great many people who were thought to be lost to follow-up were in fact legitimately in care somewhere else, often no longer in the county or state.  

At the same time, rapid tests, which have been widely used in the USA for many years as part of the testing strategy, particularly in community settings, but also in more remote areas (Alaska, Midwestern and north states) where laboratory access is limited, are becoming less popular.

One of the major reasons driving this is the problems associated with false negatives. As always there was some discussion about the amount of transmission associated with very early infection, and it was interesting that there was a greater linkage between efforts to get people to test, particularly very early after infection, and recognising the limitation of point of care or rapid tests in these contexts. 

Session F: Performance of CLIA-Waived HIV Tests and the session immediately before this examined some of these issues.

Testing was very much seen as the vehicle facilitating the linkage of patients to care. A presentation from Eugene Martin, New Jersey, demonstrated that high level linkage could occur with timely intervention.

The laboratory instrument providers also attend this conference. It seems that many of the analysts have the capacity to perform multiple tests (concurrently, but not yet necessarily all the tests we would like to see in the one run). But this really did seem the next step where the largest leap could be made. This particularly emphasised the need to link HIV testing with related testing in the STI and viral hepatitis areas.

The closing remark gives a good coverage of the scope of the meeting. It was thought there was ongoing need for the meeting and that it would have to, in the context of HIV PrEP, include STI in its agenda.