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.

Day 1: Afternoon Session

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

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

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

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

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

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

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

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

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

 

A very interesting talk today by Assoc Prof Adam Bourne today addressing many of the benefits and obstacles to reducing harm in sexual practices.

I thought the most fascinating part of the talk centered around the use of Pre-Exposure Prophylaxis (PrEP). Recently I heard there were almost as many people on PrEP in Sydney as there are on ARV's. 

The talk was largely a positive spin on PrEP, highlighting how it has improved sexual experiences, and undoubtedly the mental well being of the MSM community as well as PLHIV. However many of the issues associated with its use stem from peoples reluctance to use PrEP due to the stigma associated with taking HIV medication. I felt however the issues of condoms no longer being used by many using PrEP in casual relationships was understated. PrEP no doubt has a crucial role in prevention of transmission of HIV in serodiscordant couples, however if our message is its safe to have sex with multiple casual partners if we have an undetectable viral load or PrEP in the absence of other safe sex practices (such as condoms), the rates of other STIs will skyrocket. I know many of these STI's are treatable, though with resistance patterns seen in gonorrhea and the latency often seen in syphilis we could have serious problems on our hands. Not to mention the fact there is resistant HIV virus in the community, to which the PrEP may be ineffective. The message we should put out is yes PrEP can protect you from HIV (in most instances), however it doesn't mean that if you shouldn't use a condom if you're going to have sex with multiple casual partners. 

PrEP is still a long way off in East Timor (my current place of work), though as health resources improve could be a great aid to reduce HIV transmission.

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

 

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

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

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

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

 

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

This morning I attended a series of presentations under the heading ‘Understanding our Evolving Epidemic’ and witnessed some of the most interesting sessions I’d seen so far, some even getting a bit heated!  A few topics were about mathematical modelling and these poor statisticians are clearly used to having people leave their talks as they were very apologetic before presenting. What does it say about me that I really found them very interesting?! I’ll attempt to summarise the key messages below:

 

Mikaela Smit (Research Associate at the Department of Infectious Disease Epidemiology, Imperial College, London) discussed how mathematical modelling can support the development of evidence based policy and guidelines in relation to HIV. One model they had developed to forecast non-communicable disease burden in HIV positive patients from the Netherlands concluded that in the future most medical issues would be cardiovascular, and that 40% of these patients would have issues with medications.

In another modelling study Katharina Kusejko (ETH, Zurich, Switzerland) looked at HIV epidemiology in Switzerland and concluded that PrEP had a higher influence on HIV acquisition that condoms and ART; the modelling demonstrated that providing PrEP for 50% of MSM would prevent 250 new cases of HIV. There is currently no PrEP in Switzerland, so this study may assist the case for it.

One further modelling study was presented by a very lively David van de Nijver from the Netherlands on the Cost effectiveness of PrEP in Germany. In Germany a generic brand of PrEP has become available at the cost of €834/year compared to branded PrEP at €9512/year. His study showed that the cheaper brand could save 4 billion Euros and that Germany would break even after 10 years while most importantly averting 10,000 cases of HIV after 12 years. He insisted that Germany needs to invest now to get the savings and gain money for the future. 

 

It seems sitting through modelling studies is worth it in the end as I learned a lot! Such powerful findings that can influence public health policy. 

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

 

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

 

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

 

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

 

 

Please join us for a memorial event celebrating the life of one of Australia’s leading HIV advocates, Levinia Crook… https://t.co/N7dof5xaGa

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