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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This session at the 2017 Australasian Viral Hepatitis Elimination Conference was a series of oral abstract presentations exploring a wide range of strategies in engaging marginalised populations, including persons incarcerated, people who inject drugs (PWID), Aboriginal and Torres Strait Islander populations/communities, and Culturally and Linguistically Diverse (CaLD) populations. Subsequently, various models-of-care adopted for each population in their respective studies and community settings.

Prof Andrew Lloyd provided an overview of the care for HCV affected people in prisons in Australia. Among the total of 230K living with chronic HCV in Australia, 65k of those are persons incarcerated, with many of this cohort being PWID and/or undertaking opioid substitution therapy (OST). Prof Lloyd spoke of the challenges of treatment adherence given the frequently movement of prisoners from one area of the prison to another (or movement to other facilities) and in some cases relatively short stays. The Surveillance and Treatment of Prisoners with Hepatitis C (STOP-C) study that he leads via the Kirby Institute throutout prisons in NSW is a nurse-led model of hepatitis care (NLMC) are appears to be very effective: a 95% of treated/assessed rate and currently 100 cases treated per month, despite barriers of pharmacy technology, challenges in drug procurement, etc. Future directions in this study include: establishing an Australian national prisons hepatitis network; to implement a practical strategies, such as, a one-stop shop for testing and treatment, and a 'treatment-as -prevention' approach aiming to eliminate hepatgitis C from the prison sector.

 

Dr Phillip Read of the Kirketon Road Centre (KRC) Sydney, presented a model-of-care for Alcohol and other Drugs (AoD) clients engaging with a huge diversity of care providers. There are numerous non-medical services ranging from government services to NGO and religious-organisations contributing to the complex care model for AOD clients, offering a range of services beyond clinical treatment, such as counselling. Currently, it is estimated that at least 25K PWID living with hepatitis C are still needed to be treated. The possible solution to engage PWID populations is to use an OST infrastructure. There is, however, a few challenge facing this strategy. For example: methamphetamine IV users have less medical contact, with only 10% of them are in care. Patients often had poor venous access, poor adherence and high risk for reinfections. Furthermore, many patient’s relationships with AoD services may not be always harmonious - with many experiencing stigma and discrimination in these settings. Nevertheless, many can be tackled in AoD-specialised setting. For example, HCV RNA testing using dried blood spot will be very practical for PWID with poor venous access. Overall, the HCV elimination campaign will be benefit from co-working with peers in the model of care for AOD. 

Ms Carla Gorton and Ms Kathy Clark from Cairns Sexual Health Service in Queensland shared a personal experience of approaching and engaging with HCV in a sexual health setting/context. Their key messages were very strong: Respect, dignity, individualised care were required in providing care according to the individual’s need. Ms Gorton shared strategies for providing care for the sensitive group of people, including sexual worker and transgendered persons. Ms Kathy Clark provided contact, encouragement and transport to care. Personal engagement also helps to address issues such as shame and guilt and life priority. To reach people’s heart and mind, the networking of Cairns community members has facilitated a friendly access for hepatitis C patient to reach treatment without restriction.

Dr Malcolm McDonald is a consultant physician serving in three Indigenous health services in Far North Queensland. He shared in his presentation his plentiful experiences and great insight in approaching indigenous people in rural and remote communities. Each community has a unique history and different setting. Health Service should be in the community. It is encouraging to see that readily in-community care is available, including testing and treatment, even the in-community Fibroscan.  

 

The end panel discussion of this session emphasised the need of continuing care and information should be transferred to primary carer, as well as, the barriers of providing continuing care for these populations.

Access speaker presentations mentioned via the AVHEC website

 

A/Prof Ben Cowie's plenary talk at AVHEC17 on the Australian Progress and challenges in Hep B was highly engaging and it is certainly true that the migration laws in Australia have been discriminatory with regards to hep B patients who may be rejected for a permanent residency.

 

He also highlighted the importance of testing people from high risk countries and Indigenous background, and stressed the role of primary care practitioners who are at the forefront and are in the best position to identify who needs monitoring and who needs treatment.   

 

Another issue he mentioned with regards to GPs who have patients with chronic hep b but are untreated or maybe under monitored is the possibility of litigation down the track if these patients develop cirrhosis or cancer. It is an important issue that might just be one of the things that can drive uninterested GPs to increase their awareness and treatment of this chronic disease. 

 

Link to Ben Cowie's speaker presentation here

 

 

The global impact of chronic HBV cannot be underestimated, with 257 million people affected. More people die from chronic HBV compared to HIV/AIDS or malaria.  

 

Dr. Samuel So has launched a world-wide campaign with JoinJade, which aims to educate and engage people in the community, to increase awareness in order to achieve elimination of hepatitis B and thereby decreasing mortality and morbidity. 

 

The goal is to eliminate hepatitis B and C by 2030, and although this sounds ambitious, it is not impossible.  He recommended engagement of the government to coordinate stakeholders including the criminal justice systems to treat correctional facility inmates, professional organizations to treat patients in primary care and the CDC and local health departments.   

 

In the US, Asians and Pacific Islanders make up 6% of the US population, and these groups make up more than 60% of chronic HBV in the US.  In Australia, we see an increasing number of migrants from endemic countries and in the NT, most cases of CHB are made up of Indigenous and the CALD community.   

 

He initiated the campaign in Qinghai, China and this led to the Chinese government adapting a national vaccination program for hep B, and his efforts should be lauded.

  

His Jade Ribbon campaign has reached Australian shores, and hopefully this will lead to a better community engagement with regards to awareness, as well as better primary care involvement in identifying and treating patients with CHB. 

His talk ended with a video of Jackie Chan encouraging people to get tested and treated.

 

Link through to Prof Samuel So's speaker presentation here

 

JoinJade: Access the campaign here

 

The Australian Viral Hepatitis Elimination Conference 2017 is aimed at equipping medical practitioners with strategies to achieve this goal by the next decade.The conference has used key note speakers from around the world to deliver these strategies.

In one of the sessions titled Poster walk: DAA treatment therapies, we reviewed several recent research articles with results that, when fully implemented, will enhance the elimination of viral hepatitis in Australia.

One of the research articles we reviewed was titled: High SVR rates with eight and twelve weeks of pangenotypic Glecaprevir/Pibrentasvir: integrated efficacy and safety analysis of genotype 1-6 patients without cirrhosis.

In this presentation, we learnt that a new medication for the treatment of hepatitis C is being registered in Australia very soon. It is highly effective against all genotypes, so no genotype testing is necessary; a cost saving measure. It is also highly effective in 8 weeks, again a cost saving measure and a boost for compliance.

It can be used in renal impairment and has very few drug interactions. I am fascinated with this new medication because it would be suitable for many of my patients with compliance problems, renal problems and who are on many medications with possibilities of drug interactions with anti retroviral medications.

I have no bias or interest with any drug company. My interest is with what will enhance the elimination of viral hepatitis in Australia.

Access various Posters for DAA Treatment Therapies from AVHEC17 here

I am reporting from oral abstracts being presented at AVHEC17 regarding understanding the epidemics (modelling and surveillence).

 

The first talk , presented by Dr B Hajarizadeh (Kirby Institute, UNSW Sydney) , outlined results of Surveillance and Treatment of Prisoners with Hepatitis C (SToP-C) in New South Wales. This study was conducted in 4 prisons and revealed high HCV incidence in residents. It was confirmed that in almost all cases HCV transmission was primarily associated with intravenous drugs use. Prisoners almost always share needles so reinfection levels are twice higher than for primary infection. This study concludes the importance of introduction of wide preventive strategies including treatment as the very important part of prevention. 

 

Jenny Iversen (Kirby Institute, UNSW Sydney) stressed the importance to monitor progress towards elimination of Hepatitis C infection in Australia. The Australian Needle Syringe Program Survey (ANSPS) examined treatment within PWID over the last 5 years to ensure quality of care . The study included self-completed questionnaire and dried blood spots serological testing.  Associated factors (like age, gender, geographic location, frequency of drugs injections etc.) were also included in the study. This study was demonstrated high involvement of PWID with Hepatitis C infection after introduction of DAA under PBS. Further plans include recommendations for the RNA testing to confirm spontaneous and treatment induced clearance. 

 

Amy Kwon (Kirby Institute, UNSW Sydney) presented Part of BBV & STI Research, Intervention and Strategic Evaluation Program hold in Australia to assess level of DAA required to eliminate Hepatitis C by 2030. Using mathematical model and three possible scenarios (optimistic, pessimistic and intermediate), it was concluded that Australia finally will meet the WHO HCV elimination targets in 10-13 years. Australia invests around 1 billion dollars (2016-2020) in elimination program without restrictions on stages of Liver disease. The treatment mostly includes DAA with no Interferons; re-treatment is also allowed. Some limitations – like internal migration or reinfections – were also taken into consideration, however would not have crucial influence on the process of elimination. 

 

Recommendations for HCV testing were presented in a talk by Dr Nick Scott from Burnet Institute. He focused on models of care, treatment scale-up and care cascade among people who injects drugs in Australia. The suggestion was given for the additional testing (PCR test) to the HCV RNA. Effectiveness of such combination was confirmed statistically along with annual frequency of the testing. Such improvements in the testing system will make possible to achieve the WHO elimination target and minimize the likelihood of future outbreaks. 

 

Kelly Hoskins (Continuous Quality Improvement Facilitator, Northern Territory Government) presented data about Hepatitis B infection in the Indigenous populations. The prevalence of HBV infection within Aboriginal community is much higher (up to 12%) than in general Australian population (1%).  The project targeted on identification of those who are chronically infected and who never undergone HBV testing. The process was piloted in 5 Aboriginal communities and involved data collection and testing. The part of the project was also created (pointed?) to increase educational opportunity for the GP and other primary care providers for the proper Hepatitis B care with big attention  to find all Chronic Hep B clients and engage them to the care.  

 

Ms Maryam Alavi (Research AssociateKirby Institute, UNSW Sydney) talked about the 

burden of liver disease and comorbidities within PWID. The study revealed the importance of continuing to increase access to screening, care and treatment for individuals affected .  

 

The final presentation by Karen McCulloch (Research FellowUniversity Of Melbourne) 

characterized populations with Hepatitis C to improve access to antiviral therapy programs. This study evaluated comorbidities and other characteristics of people who are current PWID and non-PWID in NSW. The higher rate of comorbidities was reported in people with HCV infection so longer hospitalization was usually needed in case of inpatient care.

 

Link through to oral abstracts and speaker presentations here

The presentation by Professor Dore was a rapid but detailed overview of the situation of the current situation with Hepatitis C and how things have progressed over the past two years with the introduction of the Direct Acting Antiviral drugs since 2015, and more particularly, the subsidisation of these medications on the Australian Pharmaceutical Benefits Scheme in March 2016.

Professor Dore is the head of the Viral Hepatitis Research Program at the Kirby Institute at the University of New South Wales, and an Infectious Diseases Physician at St Vincent’s Hospital in Sydney.

The Real world efficacy of antiviral therapy in chronic hepatitis C (REACH-C) in Australia research report is published by his team.

He emphasised the impact of these medications as safe, effective and well tolerated drugs, in contrast to those previously available. The availability of these drugs almost without restriction to eligible patients has made a major impact on both and individual and population level. With almost a quarter of a million patients in Australia living with Hep C, knowingly or otherwise, the possibility of eliminating Hep C as a major public health issue in Australia is an achievable aim by 2026 to 2030.

Over 32,000 people were treated between March and December in 2016, representing 14% of those effected. However, figures for 2017 show declining numbers being treated compared to last year. The figures are still encouraging for people in “at risk” groups including this with Cirrhosis and those who inject drugs, and post treatment follow-up requires enhanced efforts.

Professor Dore went on to compared the “real world efficacy” of the DAAs in various situations and spoke of the REACH-C trial observational cohort, and compared the different efficacies of the different DAA regimes, and genotypes of Hep C. Various diverse models of care delivery in different situations were then discussed. Modelling of Hep C elimination in different scenarios (Pessimistic, intermediate, and optimistic) were given.

In summary, it was concluded that: Australia is leading the world in treating Hep C with DAAs, key populations for the elimination of Hep C are being reached, outcomes are favourable despite some failures in followup, and to reach the goals set by WHO, bradened models of treatment delivery are required over the next two to three years.

Professor Dore is Head, Viral Hepatitis Clinical Research Program, Kirby Institute, UNSW, Sydney Australia, and Infectious Diseases Physician, St Vincent’s Hospital, Sydney, Australia. He has been involved in viral hepatitis and HIV epidemiological and clinical research, clinical care and public health policy for 20 years.

Access Prof Greg Dore's speaker presentation here

 

 

This session was focused on the "whole system approach" and working together to deliver care to people living with HCV.

HCV affects more than 250,000 Australians resulting in up to 630 deaths from liver cancer and liver failure each year. Globally, more than 500,000 people die from HCV related causes. How can we work together with research organisation, policy makers, primary care providers, community and affected populations to change the course of HCV infection and its impact as a public health threats?

The speaker, Dr Jacqui Richmond, gave us a fantastic introduction to motivate me as a primary care provider to manage HCV in my general practice setting. In the past, there were not many primary care practitioners who wanted to be involved in HCV care in the community due to multi-factorial barriers and lack of clinical infrastructure.

With the advent of well-tolerated, short duration, interferon free DAA therapy, there is an opportunity to increase accessibility to treatment by providing care in the community setting.

Jacqui gave us very informative talk about how to deliver health services to people living with hepatitis C. Hepatitis C elimination will not occur without a whole of system approach. Elimination will not occur without GPs, nurses,community-based workers, peer workers, pharmacists, aboriginal health workers and CALD workers. Our implementation plan is to utilise a health system framework to increase demand through health promotion, increase clinical capacity through training and education, streamline clinical pathways to increase access to hepatitis C testing & treatment in the community & prison settings, establish integrated HCV prevalence and incidence over time, pilot and evaluate new interventions to increase uptake of HCV testing & treatment.

Many hands make light work. A partnership approach is the only solution. We are at the beginning of a long journey, hepatitis C is not going to be prioritised by every health professional po. We are competing for the attention of health professionals against well-resourced diseases and organisations. TOGETHER we are stronger.

Link through to Jacqui's presentation here.

Fantastic final lecture of the day at the 2017 Australasian Viral Elimination Conference! Dr Jacqui Richmond really nailed it when she said that we will not eliminate hepatitis C without a whole of system approach. A very insightful lecture into the challenges in educating the workforce and the reasons why there has been such a slow uptake of new knowledge into practice. To move DAA prescribing into the community is the essential next phase towards elimination, but this will require a change in practice on the part of GPs. Jacqui used the diffusion of innovation theory to explain how this change might happen. A very thought provoking lecture.

Jacqui Richmond has worked in viral hepatitis for the last 20 years in nursing, education, research, and policy development. Jacqui currently works at the Burnet Institute, Melbourne Health and La Trobe University, where the broad focus of her work is on building the capacity of the health professional workforce to test, treat and manage the health care needs of people living with viral hepatitis.

Link to Jacqui Richmond's speaker presentation here

 

Link 

I'm reporting from oral abstracts from the Australasian Viral Hepatitis Elimination Conference 2017 with speakers discussing Models of Care/What are the challenges ahead for hepatitis B and C elimination? 

A wonderful world-wind tour of current models of care for upscaling chronic hepatitis C treatment, mostly based around nurse-led models of care linked in with tertiary care settings. A very promising model that appears to have had great success in accessing marginalised populations who require intensive case management. Missing from the discussion however was how General Practitioners could be incorporated into this model, or indeed exploration of a GP led model of care for clients with a reduced need for support.

A particularly interesting speaker presentation was given by Dr Carla Treloar about the development of a tool to monitor the experience of stigmatisation for those engaged in the health care system - a much neglected area of research in understanding the barriers to patients seeking access to care. Clearly, all options need to be on the table if we are to reach the aspirational targets of elimination, as it is unlikely that one-model-fits-all will be sufficient to reach all of the populations concerned.

Link to the oral abstracts and speaker presentations here

I attended a collection of very interesting oral abstracts at the 2017 Australasian Viral Hepatitis Conference, each dedicated to addressing elimination of hepatitis outcomes in key population groups.

 

The first presentation by Timothy Papaluca involved a population group across 14 prisons in Victoria. It was a nurse-led HCV DAA program that evaluated the efficacy of the antiviral therapy delivered in the prison system using this model. After 17 months, 1180 prisoners had been assessed with 718 eligible for treatment and 633 prisoners having had treatment commenced. Per-protocol analysis achieved SVR12 of 95% but intention to treat analysis was only 68% with a percentage lost to freedom, highlighting the difficulties with follow up and adherence once they are out of the prison setting. With appropriate follow up and review through to SVR12 however, the prison setting provides an ideal scenario for implementing HCV DAA treatment based programs.

 

The second presentation by Marianne Martinello looked at HCV/HIV co-infection cohorts. An estimated 230,000 Australians live with chronic HCV and an estimated 2,700 of those have HCV/HIV co-infection. This cohort study evaluated HCV treatment uptake and outcomes of this cohort following DAA therapy. Annual HCV treatment uptake went from 7% in 2014 to 9% in 2015 before skyrocketing to 67% in 2016, while HCV RNA prevalence within the cohort fell from 79% to 74% and 28% in those respective years. Two key factors assisted in the dramatic uptake in treatment. Firstly, this cohort has a high proportion already linked in to HIV care and secondly, the introduction of broad based government subsidies for DAA therapy in 2016. SVR12 was 92% on an intention to treat basis and 96% among 159 individuals on a per-protocol basis, with one case of reinfection.

 

Phillip Read looked at ATSI patients at The Kirketon Road Centre, Sydney, an interesting look at their model of care for HCV. On a per-protocol basis where they were able to be followed up at 12 weeks, an SVR12 of 100% was achieved although a proportion were unable to be followed up at 12 weeks and modified intention to treat SVR12 was only 91%.

A remarkable achievement from a holistic program called “itha mari”, A Barkindji word roughly translated to “this way in the right direction”. With a patient-centred set agenda and activities such as lunches, workshops, art, storytelling, movies and food vouchers, KRC’s innovative program that is ATSI people led, showed quicker uptake than KRC’s non-indigenous patients and adherence. KRC’s commendable program with ATSI clients provides inspiration on improving follow up and outcomes not only for ATSI clients but the broader HCV demographic.

 

SIMPLIFY is an international open-label study that looked at DAA outcomes for specifically PWID group presented by Jason Grebely. It recruited participants who had recent (within six months) injecting drug use in 17 countries (19 sites) in 2016. Particiapnts received sofosbuvir/velpatasvir daily in a one-week electronic blister pack for 12 weeks. 96% completed treatment and SVR12 of 94% was achieved showing no difference between recent the PWID group and existing data for OST groups. Adherence to DAA was also highlighted in an informative pixel graph with green dots indicating compliance with daily medication while yellow dots showing missed doses, were surprisingly very low, with mean adherence of 89%. The simplified once daily regimens of DAA are more forgiving to patient adherence and the end points support the efficacy of DAA HCV treatment among recent PWID populations.

 

Darren Russell had incarcerated prisoners clamouring to be transferred to the Lotus Glen Correctional Centre (LTGC) near Mareeba in Far North Queensland once work spread within the prison community of their successful HCV treatment program for inmates. A total of 94 patients were treated with DAA therapy regimens and as of early 2017, no further existing patients at LTGC were known to have Hepatitis C in the prison.

 

Andrew Lee provided data in a prospective cohort study of patients treated by Cairns Hospital. Over a 13 month period, 481 received treatment for HCV. SVR12 results were available for only 77.8%. SVR12 results of those that followed protocol and not lost to follow up however, was 96%.

 

Greg Dore looked at HCV reinfection and injecting risk behaviour, following Elbasvir/Grazopevir treatment in patients on Opioid Agonist therapy (OAT). Of 296 patients in Co-STAR trial, 185 patients were enrolled in the follow up. Of the enrolled patients, 108 reported any drug use (injecting or non-injecting) while 47 reported injecting drug use in the past 6 months since follow up. Only 6 reinfections were found among this cohort suggesting HCV reinfection among patients on OAT following DAA therapy was uncommon despite ongoing drug use.

For more information on the abstracts and oral presentations visit the AVHEC17 website

On the first day of the 2017 Australasian Viral Hepatitis Elimination Conference, Benjamin Cowie from the WHO Collaborating Centre for Viral Hepatitis/Doherty Institute gave an inspiring summary of Australia's Progress in the management of Hepatitis B which challenges us to go further.

Figures from 2015 show 232,600 people in Australia expected to have Hepatitis B, 144,216 diagnosed, 36,534 in care and 14,636 being treated. More than 6,000 notifications for Hepatitis B were made in 2016. 

There is a marked variation within Australia of the percentage of people being managed for hepatitis B, with the Southwestern area of Sydney monitoring and treating where appropriate more than 30% of their patients with hepatitis B, but in some areas in Australia areas this figure is as low as <5%.

The challenge then is to work at screening. Asking where a person or their parents were born, or whether they identify as Aboriginal or Torres Strait Islander will help to pick up 2/3 of potential cases. Late diagnosis leads to a marked increase in decompensated cirrhosis and liver cancer.

If we fail to look for Hepatitis B in the appropriate places, we are doing our patients a great disservice, and a potential long term medicolegal disservice to ourselves.

Link through to A/Prof Ben Cowie's presentation here

Dr Maia Butsashvili discussed Hepatitis C elimination in Georgia. 

Of a total national population of 3.7 million inhabitants, the incidence of chronic Hepatitis C in Georgia is 5.4% (i.e. 150,000 people).

Hepatitis C is found in 3 population subgroups in Georgia - PWID, MSM and healthcare workers; with the peak incidence being men in the 30-49 age group.

Georgia underwent a period of political and economic upheaval in the 1990s with the collapse of the Soviet Union. Injecting drug use was at its peak and healthcare procedures were compromised. Blood transfusions, dental and obstetric procedures (especially terminations of pregnancy as a form of contraception) are thought to be the source of the health care related hepatitis C infections.

With the help of the CDC, Georgia is running a pilot program to eliminate Hepatitis C in  its population.The Georgian government has supported this initiative, and the pilot is aiming for 90% diagnosis, 95% treatment and 95% cure of its Hepatitis C population by 2020. Coupled with this aim are the strategies of harm reduction in PWID communities (needle syringe and OST programs) and preventing transmission of Hepatitis C in the healthcare setting.

The pilot was initially established at 4 sites in 2015, and telemedicine support for difficult cases was provided by Boston specialists. All results are reviewed by a committee before treatment was selected and commenced. Treatment was initially with a combination of Sofosbovir, Ribavirin, and Interferon and more recently Harvoni has been added to the treatment regime. There were initial concerns that the treatment provided would be sold as there are no treatment programs in surrounding countries; this has been limited by fortnightly dispensing.

To date, Georgia has treated 30,000 of its target group of 150,000 and has screened half a million people from 2015 to 2017.  SVR in 2015 was 85%, and has risen in 2016 to 95%- the difference being the introduction of Harvoni and the treatment of the sickest patients initially. SVR is missing in 25%. 

Georgia has extended the pilot to 28 centres, and is now targeting the PWID population to improve detection, prevention and treatment in this community.Georgia has established a treatment centre in a drug treatment clinic (OST) and is using peer workers help PWID clients access and attend healthcare providers.

Other plans to scale up screening include providing incentives to primary care providers and delivering a mass information campaign.  It doesn't sound like they are going to stop.

Link through to Dr Maia Butsashvili's Speaker Presentation here

This 1 hour lunch time poster session presented an overview of different studies presenting STI epidemiology amongst MSM & heterosexual populations. 

 

  1. Florence Lot: STI co- infections at HIV diagnosis in France

Aim was to analyse the frequency of STIs in new HIV infections between 2012- 2015, using the mandatory HIV surveillance system which has, since 2012, collected data on bacterial STIs (CT, NG, LGV, syphilis). These had to be reported if detected at time of or in the 12 months prior to HIV diagnosis. 

Analysis by transmission group and trends. Reported as ‘HIV/STI co-infection’.

Result 1: 

Frequency of STI/HIV co-infections in adults by HIV transmission group & sex:  14.6% globally (26.4% MSM; 11.3% male & 5.8% females born in France; 5.1% male & 2.5% females born abroad; 7.2% male & 8.7% female IDU).

Result 2:

Frequency of STI/HIV co-infections in adults by HIV transmission group & year of HIV diagnosis: Significantly increased over time with 12.6% in 2012 to 18.3% in 2016. By transmission group, this increase was only significant for MSM from 22.1% in 2012 to 31.9% in 2016.

Result 3:

 Frequency of STI/HIV co-infections in adults by HIV transmission group and bacterial STI: Syphilis on the rise especially in MSM, heterosexual men were more often co-infected with syphilis and NG than heterosexual women who were more frequently infected with CT. Rectal LGV dx only in MSM. 

Conclusion:

HIV & STI co- infection has increased over time and affect almost 1/3 of MSM newly dx with HIV. Highlight importance of testing, treating index + partner. 

There was a question around testing frequency in France- was once per year and is now 3 monthly, including viral hepatitis screen (not sure if this had increased from yearly..). Another Q around high syphilis prevalence- confirmed that asymptomatic people are screened. 

A comment from a clinician from the UK regarding HCV, they are seeing a significant increase in acute HCV infections not associated with IDU amongst HIV negative MSM population, same in France? A- don’t have the data. 

 

  1. Flavia Kiweewa Matovu: STI acquisition among women using a variety of contraceptive options in Uganda

LARCs are being widely promoted, not much data on STIs in LARC use. High risk female population in in Uganda, established STI increases risk of HIV transmission.

Prospective cohort study- ASPIRE study.

Results:

Analysis population: 2264 women (50.2% from Sth Africa). 817 cases of STIs detected over 3,440 person years of follow up.

CT: 408 cases/ incidence of 11.86/100 person years

NG: 196 cases/ incidence 5.70/100 person years

T.vaginalis: 213 cases/ incidence 6.19/100 person years

(No mention of HIV, syphilis etc).

Conclusion: 

Incidence of CT & NG were not different across contraceptive methods.

Incidence of T.vaginalis was significantly lower for DMPA (medroxyprogesterone acetate injectable contraceptive), implant and NET-EN (norethisterone enanthate injectable contraceptive) users compared to IUD. 

Significantly lower rates of T.vaginalis among users of progestin- based methods, likely due to hypoestrogenic states. 

Limited by lack of randomisation to contraception method. 

Question around extra- genital sites being tested- yes, serology and genital swabs. 

Another question around relative risks being adjusted for baseline sexual risk- yes, adjusted for baseline age, sexual risk. 

 

3) Jeffrey Parsons: Differences in biological and behavioural HIV risks before, during and after PrEP use among a national sample of GBM in the USA

PrEP & STIs- Does going on PrEP lead to increased condomless sex (CAS) and thus higher rates of STIs OR are the increases seen in STI rates due to the required quarterly testing…?

Limitations to these data: Predominately Caucasian, employed and well educated population. Half were in a relationship, half were single. The sample were also early PrEP adopters.

Results: 

Cross sectional between group analysis: the 823 PrEP naïve men had significantly lower STI infection rate (4.2%) than those 77 currently (10.4%) or 17 formerly (11.8%) on PrEP (p < 0.02), with men on PrEP also reporting more acts of CAS (p <0.001). 

Within- person longitudinal analyses of 181 men reporting PrEP use indicated a non- significant increase in the odds on an STI diagnosis while on PrEP  and after discontinuing (OR= 1.25, p= 0.55; OR= 1.43, p= 0.53 respectively), compared to before starting PrEP. There were also no significant changes in CAS while on PrEP (OR = 1.09, p = 0.76) or after PrEP discontinuation (OR = 0.48, p = 0.10) compared to pre-uptake levels.

Discussion:

Using between- subjects comparisons of all participants, some evidence was found that GBM on PrEP have higher levels of both behavioural and biological risks, though findings were mixed when examining multiple time points. 

Using within- subjects comparison over time among only those who had been on PrEP during at least one of the three visits, the rates of CAS increased while on PrEP but returned to pre- PrEP levels after discontinuation. They did not see a statistically significant increase in odds of STI infection. 

Comment:

Important not to lump all GBM into one category. Differences in behaviour, risk and motivation for accessing and using PrEP. 

Early adopters- so more study required to determine the behavioural differences in early and late PrEP adopters. 

Question from the audience regarding the sites tested for STIs- in NYC, only 50% of participants had completed a rectal swab which could affect the data. 

88% completed urine and serology test.. pharyngeal swab around 60% (sorry missed that comment). 

Highlights the importance of a complete STI screen to ensure both a public health and epidemiological perspective. 

 

 

4) Marie Suzan- Monti: Partner notification (PN) of STIs among MSM on PrEP: s sub- study of the ANRS- IPERGAY trial

In France, there are no PN specific guidelines, and scarce PN information. Data on 275 HIV negative men from the ANRS- IPERGAY PrEP trial who reported an STI were used. 

Results:

Out of 275, 250 reported at least one previous STI. Of the 250, 172 had informed their partner (138 their occasional partner and 83 their main partner). 

No significant socio-demographic difference between this who did and did not notify their partner. 

Less likely to notify their main partner when most recent sexual contact was through condomless sex with an occasional partner (aOR(95%CI) 0.31 (0.14; 0.68), p=0.03).

Older MSM less likely to inform occasional partners (aOR(95%CI) 0.44(0.21;0.94), p=0.03).

Those participating in chemsex at most recent sexual encounter were more likely to inform sexual partners (aOR(95%CI) 2.56(1.07;6.09), p=0.03). 

Discussion:

Condomless sex with occasional partners was identified as a barrier to PN, and chemsex a motivator for PN. 

Not measures if health care workers were notifying partners. 

Hopefully these data support the need for systematic PN services, support and information in France- highlights how well Australia (speaking from a Victorian perspective) undertake PN form a top down approach. 

 

 

5)  Kristin Wall: Predictors of genital ulceration in HIV negative sero-discordant couples in Lusaka, Zambia.

Genital ulcers are a known risk factor for HIV transmission, and little is known about the risk factors for genital ulcers, limiting early detection and treatment. 

Exposure data were taken from HIV serodiscordant heterosexual couples every 3 months at ART uptake or HIV transmission. Associations were evaluated between exposures measured during the visit prior to the presentation with an ulcer. 18 year longitudinal cohort study (1994- 2012).

Results:

1393 M+F- couples were followed for 2756 couple- years, and 1656 M-F+ couples were followed for 3216 couple- years.

Risk for genital ulcer in HIV- women was associated (p<0.05) with bilateral inguinal adenopathy (BIA) (aHR=1.9), genital inflammation (GI) (aHR=1.5-1.9), male partners non- STI GI (aHR=2.9) and increasing number of previous pregnancies (aHR=1.1).

Risk for genital ulcer in HIV+ women was as above (BIA- aHR=1.5; GI- aHR=1.5-2.0; male non- STI GI- aHR=2.0), as well as late HIV vs early HIV (aHR=1.5) and being pregnant (aHR=0.7).

Risk in HIV- men was associated with BIA (aHR=1.8), STI GI (aHR=2.9) and non- STI GI (aHR=1.4), female partners ulcer (aHR=1.7), and being uncircumcised (aHR=1.7). Being uncircumcised with foreskin smegma was independently predictive (aHR=3.2). 

Risk in HIV+ men was associated with STI GI (aHR=2.8), HSV-2 positivity (aHR=2.5), late HIV  vs early (aHR=1.7) and being uncircumcised with foreskin smegma was independently predictive (aHR=2.4). 

Discussion:

Ulcers were also tested for syphilis, prevalence of chancre 2-3%  

BIA & GI may be early indicators/ risk factors for genital ulceration. Uncircumcised men with foreskin smegma either HIV +/- were at increased risk of ulceration. 

HSV-2 positivity not a predictor once controlled for genital ulcers and only a predictor in HIV+ men. 

Suggest: Targeted screening amongst those with advanced HIV infection. 

 

 

 6) Cari van Schalkwyk: Are associations between HIV & HPV transmission due to behavioural confounding factors or biological effects? 

This presentation was a mathematical modelling study to assess whether confounding for behavioural factors and network effects sufficiently explain associations between HPV & HIV infection. 

MicroCOSM is a dynamic individual- based network model and was used to simulate epidemics of HIV & 13 oncogenic HPV types.

Results: 

The mean unadjusted hazard ratio of HIV acquisition after detection of an oncogenic HPV type is 3.2 (95% CI 2.6, 3.8); and the mean unadjusted hazard ratio for the effect of HIV on newly detected HPV is 3.7 (95% CI 3.4, 4.1).

Discussion:

The study results are similar to observational study unadjusted results, suggesting that observed associations between HPV & HIV transmission could be attributed to confounding by behavioural factors and network- level effects. The author concluded that primary prevention with the HPV vaccine may therefore not be beneficial in HIV prevention. 

There was also no further increased risk in the presence of cervical lesions. 

 

The study group have a proposal for a clinical trial using the HPV vaccine to determine if this decreases HIV transmission although no funding as yet. 

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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.

As if there weren’t enough treatments for Hepatitis C already, results of another Hepatitis C treatment trial were presented on Monday at IAS 2017.

Karine Lacombe of Saint-Antoine Hospital in Paris presented findings from AbbVie's phase 3 EXPEDITION-2 trial, which evaluated an 8-week regimen of glecaprevir/pibrentasvir for people with both HIV and hepatitis C.

Glecaprevir is an HCV NS3/4A protease inhibitor and pibrentasvir is an NS5A inhibitor. Both are pangenotypic, or active against all HCV genotypes. The two drugs have been co-formulated in a once-daily combination pill, to be marketed under the brand name Maviret.

Studies in the DAA era have shown that HIV-positive people generally do as well on interferon-free regimens as those without HIV – though it is important to take into account the potential for drug interactions between DAAs and antiretrovirals – and they are no longer considered a "special population." Yet European and US HCV treatment guidelines currently do not recommend shorter treatment for people with HIV and HCV co-infection.  A shorter course of treatment could potentially improve adherence and reduce cost.

EXPEDITION-2 enrolled 153 HIV-positive people with chronic hepatitis C in Europe, the United States and Russia. More than 80% were men and the median age was approximately 45 years. About two-thirds had HCV genotype 1 (mostly with harder-to-treat subtype 1a), followed by genotypes 3 (17%) and 4 (11%); a small number had genotypes 2 or 6.  People with Hep B co-inbfection were excluded.

Sixteen participants (10%) had liver cirrhosis, and most of the rest had absent or mild fibrosis. Nearly 20% were previously treated with interferon and ribavirin, and three had also used sofosbuvir (Sovaldi).  Study participants had well-controlled HIV infection with a median CD4 count of nearly 600 cells/mm3.  All but nine were on antiretroviral therapy, and about three-quarters of treated people were taking the integrase inhibitors raltegravir (Isentress) or dolutegravir (Tivicay), which were shown to have minimal interactions with glecaprevir and pibrentasvir.  They had variable backbones including TDF, FTC, TAF, lamivudine.  I’ve included the drug-drug interaction profiles out of interested, as presented at the session.

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Participants without cirrhosis received glecaprevir/pibrentasvir for 8 weeks, while those with cirrhosis were treated for 12 weeks. Everyone received the study drugs and there was no placebo arm.

 Treatment was highly effective, with 98% having continued undetectable HCV RNA at 12 weeks post-treatment (SVR12). The cure rate rose to 99%, with no virological failures, for people without cirrhosis who were treated for 8 weeks.

A single patient with HCV genotype 3 and cirrhosis, who reported less than complete (85%) adherence, experienced virological failure during treatment. Another participant had missing data at 12 weeks post-treatment, but returned for care at 24 weeks post-treatment and was found to be cured.

 Glecaprevir/pibrentasvir was generally safe and well tolerated. Adverse events were similar to those seen in studies of HIV-negative people. One participant with cirrhosis stopped treatment early due to an adverse event that was not considered drug-related (stroke and brain haemorrhage). The most common adverse events were fatigue, nausea, headache, and nose and throat inflammation.

 "These results suggest that the glecaprevir/pibrentasvir regimen could be the first 8-week, pangenotypic treatment option for HCV/HIV-1 coinfected patients without cirrhosis," the researchers concluded.

This could be a bonus for co-infected patients but caution with drug-drug interactions is still an issue.  However, given the short duration of therapy these may or may not be significant.

 

Greetings from the 9th IAS Conference on HIV Science in Paris, France. As usual the content is broad, but (as the new branding signals) science dominates the agenda. On this occasion there is no great breakthrough or advance that might electrify the event and set tongues wagging.

From a global access to care point of view it is clear that funding is at best flat-lining (and this has been the case for the past 7 years) and in some cases falling as we move well beyond the Millennium Development Goals and firmly into the era of the Sustainable Development Goals.

It seems unlikely that the Trump administration will increase U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding and most likely will withdraw funding during this Presidency. According to UNAIDS. 19.5 million people are now receiving ART around the world. However it is estimated that 40% of all those infected are unaware of their HIV-status and that for every 1 person dying from AIDS every year 2 become HIV-infected. Thus, while the UNAIDS 90-90-90 goals are commendable, we are a long way from getting even close to achieving them. In this context the goals are in danger of being perceived as an impossible dream.

 

Such musings inevitably focus attention on the critical need for an effective vaccine to truly augment efforts to eradicate the HIV pandemic. Unfortunately there is little news on this front and we need to be realistic and understand that this may be a task beyond us given our current understanding of HIV pathogenesis. This is also the case with the cure, which despite intensive investigation over the past decade has little to show for all the effort. As with the HIV vaccine, a true advance will most likely come from a profound and unpredictable (and unfundable) paradigm shift in our understanding of HIV pathogenesis and immune protection. Let’s hope that occurs in our lifetime, but if I were a betting man…

Better news comes from the fields of therapeutics and PrEP

PrEP rollout is going well but is to a large extent restricted to those countries in which the research has been conducted – France, USA and Australia. Efforts are being made to introduce PrEP into Africa, but a major drawback is the lack of efficacy often seen in younger women (16-24 yo) with oral TDF/FTC. This may be overcome with the use of injectable long acting ART agents like cabotegravir and rilpivirine, and also possibly intra-vaginal rings containing ART (e.g. Doravirine). These rings could also be impregnated with other pharmaceuticals (e.g. oral contraception, anti HSV products, antimicrobials). We await the science.

This conference also saw the presentation of the phase 2b RCT of 2 drug maintenance of initial triple therapy induced virological suppression with long acting injectable cabotegravir and rilpivirine. Over 2 years in the once monthly injection group no virological failures were observed. This once monthly strategy is now enrolling participants in pivotal phase 3 RCTs. Joe Eron (UNC, USA) who presented the data at the conference said that the 2-monthly strategy is also still under active consideration. The result was reported by a few media outlets including the BBC.

See Injections 'next revolution' in HIV - study by James Gallagher:

http://www.bbc.com/news/health-40703336

 

 

The conference was also the venue for the public presentation of Phase 3 RCTs of Gilead’s unboosted once daily InSTI ‘Bictegravir’ versus Dolutegravir. The results of 2 Phase 3 placebo-controlled, double-blinded RCTs were presented; one with a backbone of TAF/FTC in both arms and one with BIC/F/TAF versus DTG/ABC/3TC. Non-inferiority was demonstrated in both cases with good tolerability across all groups. Importantly, no resistance was seen in the rare virological failures in both studies, consistent with what we have seen with DTG to date in trials and clinical practice. It is expected that the BIC/F/TAF fixed dose combination product will be licensed in the USA by Q4 2017 and most likely be listed on the PBS by Q3 2018 in Australia.

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This IAS 2017 session was dedicated to addressing HIV in 4 main populations that have been identified as “key” around the world, including migrants, sex workers, men who have sex with men and people who inject drugs.  The studies presented had varied countries of origin which helped to demonstrate that key populations vary worldwide.

 

The first presentation presented data from the aMASE study to determine the rate of migrant acquisition of HIV in Spain. This was a multi-centre cross sectional study that collected data from both patient questionnaires and clinical notes in 6 regions around Spain of patients who had been diagnosed with HIV in the preceding five years and had lived in Spain for a minimum of six months at time of diagnosis.  A range of information was collected including socioeconomic, behavioural, migratory, previous HIV testing, CD4 and viral load levels and resulted in a statistical analysis to determine most likely time and place of acquisition.

 

Of 710 participants, there was sufficient data to estimate time of acquisition for 685.  77% of the analysed respondents were men and 60% were MSM, 20% heterosexual women and 14% heterosexual men.  Median age was 35 years and median time in Spain was 9 years.  The region of origin were Europe 17%, Latin America 64%, Sub Saharan Africa 13% and others 6%, this trend is reflective of the large numbers of Latin American people migrating to Spain and so mirrors broader population trends.  A total of 72% of the sample were estimated to have acquired HIV whilst living in Spain.  Factors associated with post migratory acquisition were Latin American origin, younger age and increased duration of stay in Spain and the proportion was also higher in MSM.  This highlights 2 key populations that are being failed with regards to prevention, migrants (especially Latin American) and MSM and suggests who needs targeting in national prevention strategies, such as PrEP.

 

The second presentation presented data collected on transactional sex in MSM from Vancouver, Canada and has been blogged about by one of my colleagues, so I will only briefly touch on this presentation as it has been covered more extensively elsewhere.  The motivation for this study was to ascertain whether transactional sex in MSM is a causative factor in HIV transmission.  The study objectives were to determine prevalence of transactional sex events and evaluate temporal trends and consequences such as HIV risk or acquisition in a prospective cohort study.  Results of 690 participants and 8990 sexual events revealed that transactional sex was rare with 2.4% reporting receiving, 1.2% reporting giving, 0.3% reporting both giving and receiving.  To assess HIV risk, the investigators focussed on condomless anal sex and HIV concordance, discordance and unknown status and there was no statistically significant difference between these groups and whether they engaged in transactional sex or not.  Factors that did increase the risk of transactional sex included low income, loneliness, substance use of the partner (GHB and methamphetamine) and meeting online.

 

A third presentation of a study nested into France’s Ipergay study presented data about the suitability of on demand PrEP for chemsex participants.  The objectives of this sub study were to better characterise chemsex participants and study the association between engagement in chemsex and PrEP use.  Chemsex participants were found to be more likely to use anxiolytic medications, be sensation seeking and have increased numbers of sexual encounters.  They were also more likely to have condomless anal sex, hardcore sexual practices and perceive themselves to be at higher risk of HIV.  What was notable was that they were also more likely to use PrEP perhaps due to their justifiably perceived higher risk.

 

Fourth was a study from south Africa on health outcomes of children of female sex workers, who have about a 60% HIV prevalence rate.  This was undertaken in the form of a cross sectional study at sex work venues and mobile health centres from September 2015- February 2016.  The mothers completed a questionnaire and HIV testing.  The children were also tested for HIV and growth parameters measured.  Results demonstrated maternal HIV prevalence at 67.5% and ART at 63.6% and overall HIV prevalence in their children was 3%, rising to 4.5% in HIV positive mothers.  Full vaccine coverage decreased as the children got older and 27% of children’s growth was stunted, a reflection of their nutritional status.  This study really highlighted that health services for sex workers would be well placed to expand into caring for the children of their key population as well.

 

The Vietnamese DRIVE-IN study presented data on HIV and HCV incidence and risk in people who inject drugs in a longitudinal follow up of 204 eligible participants.  Of the 204, 105 were HCV positive only, 94 were negative for both HIV and HCV and 5 were HIV positive only.  No HIV seroconversions occurred during the 1 year follow up period but 18 HCV seroconversions occurred.  Factors associated with HCV seroconversion included more injections and being arrested. This data supported the perception that HIV was low in this population but also brought to light that HCV needs to be addressed as a priority for this population.

 

Finally, data from a Kirby institute run, multi-site Opposites Attract trial presented more data to support treatment as prevention in male serodiscordant couples.  A total of 358 couples enrolled worldwide and the total couple year follow up was 591 years.  During this time, 3 seroconversions occurred.  All 3 seroconversions reported condomless anal sex outside the principal relationship and phylogenetic analysis of the seroconverted participants and their principal partner demonstrated overwhelmingly that there were no linked transmissions.  The data demonstrated that in over 12,000 acts of condomless anal sex with a virally suppressed HIV positive partner and a HIV negative partner not on PrEP, there were no transmissions of HIV.

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This symposia session was the only session in the conference focussed entirely on women's health. It was a fantastic introduction for me to the management issues of HIV positive women from adolescence to menopause as I have had minimal exposure especially to adolescent HIV. Yesterday we heard from Associate Professor Darren Russell regarding the increase in HIV diagnoses in Aboriginal and Torres Strait Islanders in Northern Australia and I am concerned that being based in this region I unfortunately will be involved in more cases of adolescent HIV in the near future. Globally two thirds of new HIV infections are in adolescent girls.

I was surprised when I learned the epidemiology of HIV in women.

HIV is the leading cause of death among women aged 30-49 years globally. 

In hundred thousands:

HIV 241.9

Ischaemic heart disease 150.5

Maternal conditions 148.4

Stroke 139.5

Breast cancer 130.9

Tuberculosis 96.4

and the third cause of death globally for those aged 15-29 years.

Does ART modify hypertensive disorders in pregnancy? Or obstetric haemorrhage? Data is inconclusive.

But the take home message is there is more to antenatal care than prevention of mother to child transmission.

There was a slide regarding the global burden of disease in adolescents. As a GP I feel I am in an ideal setting to screen for many of these issues as I see a higher proportion of young females. These include vaccine preventable diseases, under nutrition, sexual health, violence and injuries, mental health and substance use disorders.

 

 

 

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Is there a role for treatment intensification with Maraviroc in addition to a standard cART for naïve patients with low CD4 counts, and will it decrease the risk of progression to AIDS? (ANRS 146 – GeSIDA OPTIMAL)

There is no clinical evidence that of successful treatment intensification by the addition of a 4th antiretroviral agent; despite numerous trials.

This double-blinded trial in France , Italy and Spain compared Maraviroc (+cART) to placebo (+cART).   Over 400 naïve, HIV-1 infected patients with an AIDS defining illness or CD4 cells < 200cell/mm^3 were enrolled.

The primary endpoint was the occurrence of a severe morbidity (AIDS, SNAE, IRIS, Death or other HIV related disease). Baseline characteristics were comparable.

In the 72-week follow up period; treatment intensification made no impact on the risk of infections, serious events, mortality, virilogic control or on CD4 count recovery. A post hoc analysis suggested Maraviroc might demonstate benefit on the occurrence of clinical events in the first 6 months of treatment, however this benefit “subsequently disappeared”.

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Peripheral Arterial Disease. 

HIV infection and the risk of peripheral arterial disease; an observational, longitudinal cohort of HIV positive U.S. Veterans matched 1:2 with HIV- uninfected veterans matched for age, race, ethnicity and site.  The sample was greater than 90,000.

The investigator presented data from 7 years of observation of this very large cohort. The participants were followed for peripheral arterial disease (PAD), death or their last follow up date.

Cumulative incidence of PAD was calculated and adjusted for confounders. A regression model was used to examine the association between HIV positivity, CD4 count and PAD after adjusting atherosclerotic risk.

In this study, the HIV positive veterans had significantly higher rates of peripheral arterial disease when compared with HIV uninfected veterans.

The speaker encouraged checking for ankle/feet pulses as PAD is often not diagnosed – this seems like a extraordinarily simple ‘practice-changing’ intervention for primary care.

An absence of a pulse should prompt vascular referral. Smoking cessation obviously remains a vital health intervention. A low CD4 cell count was also a strong predictor of PAD, with almost a 2-fold increase in the risk. Importantly, a CD4 count of greater than 500 showed no increase in risk. Lipid lowering treatment will be part of a future analysis and was not examined in this paper.

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