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.

The Round table meeting made some interesting points concerning the recent instigation of PrEP in the UK and France.

 

 Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot, France) showed that daily and on demand PrEP is cost effective for the community. More importantly it has helped take the fear of sexual activity and anxiety from a population that are over represented  when it comes to mental health care issues. He felt that PrEP is still not reaching high risk groups such as  young MSM, migrants and the trans population. Young MSM are a particular problem  in that they often feel stigmatized about their sexuality and unwilling to  engage with the medical profession. They may also be in some denial about their HIV risks and are a difficult population to ensure compliance with medication. Social media apps eg Grindr, Hornet and Planet Romeo are very important  resources for HIV ,PrEP and PEP education.

 

PROUD and IPERGAY studies have confirmed the effectiveness of daily and intermittent/ on demand Truvada.(4 tabs). Maraviroc was not shown to be an effective PrEP agent. Current studies with TAF/FTC are promising as is injectable Cabotegravir LA. Topical drugs such as vaginal gels also have an important place. The possibility of future over the counter PrEP raised some concern by the panel who felt  medical intervention is needed at some point in the PrEP pathway.

 

Emma Devitt from the Dean Street Clinic Soho, UK showed some impressive rates of decline in new HIV diagnoses in the last year. She felt this was due to a combination of factors their clinic offers including:

-frequent screening for HIV 

-rapid ART instigation for HIV positive people

-regular STI screening and rapid Rx of STI

-use of PEP and now PrEP

 

A very informative and topical meeting  from some incredibly dedicated and progressive doctors.

 

also see blogs from Rebecca Houghton and Emma Clements on this topic

Tagged in: EACS 2017 PrEP access

The welcome to the conference was at 2pm…and I had already eaten so much “information” gelato I was decidedly full…however as with all good food (for thought).. there is always room for more…so I decided to sample the “Round Table: Modles of HIV testing and delivery of PrEP”

 

This session was opened by Prof Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot ) who highlighted some of the issues limiting or preventing the implementation of PrEP in Europe.  He discussed the cost benefit of people on PrEP versus the lifetime cost of treating those living with HIV and the distinct need to highlight PrEP's feasibility. He discussed the need for close partnerships with the community and political support to facilitate PrEP implementation.

 

Dr Emma Devitt from Dean St Clinic (also see Emma Clements post) highlighted their exemplary model of testing using cutting edge technologies to facilitate patient’s access, testing availability, results turn around and treatment options.  Amongst routine STI services, Dean St service provision includes on site laboratories, HIV and Hepatitis specialist clinics, HIV oncology clinic, Urology and dermatology services, Dietetics, Contraceptive/LARC services, Anoscopy, ED/Psychology/Psychosexual and a Pharmacy service. Most impressively to facilitate their ‘self-testing’ model they have guided self-sampling videos embedded in the mirrors in their bathrooms to guide clients through the process self-collected swabs.   Of course there was mention of the GeneXpert technology which provides extremely quick results turn around but what struck me here was the added option of a web link to the next available treatment appointment should your result be positive - its the total package of care!  Statistical modelling showed that since the introduction of the Express model at Dean St, STI’s are treated 8 days faster than previously and for every 2 people diagnosed with a bacterial STI’s one partner was spared exposure suggesting public health implications and cost savings.  This rapid STI diagnosis and treatment is thought to be one of the causative agents in the recent dramatic reduction in HIV diagnosis seen at Dean St.

 

Gus Cairns editor of AIDMAP and co-ordinator of PrEP in Europe talked through his personal experiences of HIV diagnosis in 1985 and why he is such an advocate for PrEP in the modern era.  He talked about 20 years of fear inducing messages when condoms were advertised as the only responsible way to have sex. PrEP had brought with it a reduction in the crippling anxiety that many MSM experienced during sex, in PrEP the protective behaviour is separate in time from the risky action itself and described it as ‘enhancing’ sex by reducing the fear. He went on to highlight that PrEP is not enough and in a powerful slide simply put the U=U message (undetectable=untransmissible) reminding me that we need to be confident and unanimous in this message.

 

 

Finally and to finish the session was a round table of questions in summary.  These addressed the following questions… How do we approach and include the young? How can we promote PrEP to wider audiences? Is there a future for over the counter PrEP?  Much like describing all the culinary experiences of Gelato tasting in Milan it is impossible to capture the sheer depth and flavour of the responses but needless to say I will find room for more taste sensations tomorrow!

Day 1, post number two.

This afternoon I attended a round table discussion on PrEP, after the opening ceremony. It seemed everyone in the conference was there as the room was packed! 

 

 

Rebecca Houghton will be blogging about this in more detail but I wanted to touch on the excellent presentation by Dr Emma Devitt from Dean Street Clinic in London as this was another analysis of a model of care, but of a single service. It is well known that the Dean Street model of care is progressive and hearing her discuss the way the service has actively adapted to the needs of the community in it's location, design, and flexible staffing is a lesson we should absorb. The clinic's redesign in 2014 to include an express service running 6 days a week is of note as it takes full advantage of many technologies that are available to us; videos explaining self-specimen collection that play within the mirror in the bathroom; and their GeneXpert has been calibrated to bypass a middle man and text clients their results directly. Inspiring stuff! She highlighted that express models still require medical staff on site to support nurses and health care assistants, and also discussed how the delivery of PrEP is evolving in their clinic with nurse prescribing. 

Is “on-demand” PrEP a suitable tool for MSM who participate in Chemsex?  From ANRS-Ipergay.

This was in an IPERGAY sub-study of 331 participants during the open-label extension (OLE) phase of the study who reported drug use during at least one sexual encounter.

 2 monthly data was collected regarding drug and alcohol use, sexual behaviors and PrEP adherence during the participant’s most recent sexual encounter(s) and analyzed with a multivariate regression model. PrEP use was self-reported by participants.

Among the MSM participants, 29% reported Chemsex at least once during the follow up period and16% reported chemsex at all visits.

Socio-demographics between those labeled chemsexers were not different from those labeled non-chemsexers, other than a higher use of anxiolytics in chemsexers.

 After adjustment, chemsexers were found to be more likely to use PrEP (OR (95% CI = 2.18 (1.04; 4.49)) and less likely to use condoms (p< 0.001)

Of note, when MSM reported chemsex during their most recent sexual encounter there was a grater likelihood of receptive anal sex, hardcore sexual practices, casual sexual partnerships and a higher perception of risk. All p-values <0.001

This important and interesting sub-study suggests that PrEP may therefore be a suitable tool for HIV prevention people practicing chemsex.

 

Tagged in: 2017 IAS Conference

IAS2017 Tuesday 11 am 25/7/2017

 

This session provided updates from various oral, topical and long-acting injectable PrEP clinical trials.

Sheena McCormack presented long-term PROUD study data from 2-4 years post enrolment.  This indicated that reduction in HIV incidence was sustained, and confirmed high adherence and durable effectiveness of PrEP in the study population.  However, as suspected rectal chlamydia and gonorrhoea and syphilis diagnoses remained high re-iterating the need for structured regular followup of these high risk patients.

A qualitative analysis exploring PrEP perceptions among PROUD participants, found that most viewed PrEP as a temporary HIV prevention option. Participants described psychosocial benefits in terms of reducing fear and providing relief when taking PrEP.  They didn’t discuss some of the stigma that still persists in the community about people who take oral PrEP however.  Acceptability seems to be increasing however.

Guillemette Antoni presented data from a double-blind, randomised sub-study of IPERGAY which found a significant reduction in HIV infection risk with on-demand TDF/FTC vs. placebo, in MSM having infrequent sex.  Oral PrEP with tenofovir/emtricitabine is now subsidised in France.

Sharon Hillier presented data from the completed FAME study.  This study found that FGT and plasma drug levels of dapirivine were not affected by Lactobacillus or G. vaginalis microbiome.  Tenofovir levels in FGT and plasma however are adversely affected by vaginal disbiosis (bacterial vaginosis). The potential influence of vaginal microbiome on topical and plasma PrEP drug levels emphasises the need for HIV prevention products that work in women with vaginal dysbiosis.

Ian McGowan from the USA presented data from the MWRI-01 multi-dose Phase I study.  They found long-acting IM rilpivirine to be safe. Drug accumulation was significant in plasma, rectal, and female genital tract (FGT) tissue.

Finally, Raphael Landovitz presented data from HPTN077, a double-blind, randomised, placebo-controlled tolerability and pharmacokinetics trial.  They found LA cabotegravir was well tolerated at 800mg/600mg doses in HIV-uninfected low-risk males and females.

Updated safety, acceptability and pharmacokinetic data on LA IM rilpivirine and cabotegravir provides hope for the viability of long-acting injectable PrEP formulations and circumvention of the adherence challenges associated with oral or topical PrEP.

Tagged in: 2017 IAS Conference

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

ASHM ASHM