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.
HPV vaccination and National Cervical Screening Program
HPV vaccination has been a major success in Australia.
“Cervical cancer vaccine”, not HPV vaccine - unsure how the public would respond to a vaccine against an STI.
Introduced in 2007 in females, and 2013 in males in schools.
Vaccination in schools is much more effective than trying to get the same people into consulting rooms.
3-dose coverage in 70% of females, and 60% of males.
4v-HPV quadrivalent vaccine effective against types 6, 11, 16, and 18.
Moving to a 2 dose schedule as other countries have.
Easier to roll out.
2 doses spaced > 6 months apart just as immunogenic as 3 doses in adults.
Approved by WHO in 2014.
Increasing interest in the 9-valent vaccine which includes all the oncogenic types.
Implementation of a 2 dose schedule likely to occur at same time as a switch to 9-valent vaccine.
Incredibly safe, no evidence of autoimmune diseases.
Incredibly immunogenic, with high levels of antibodies sustained for over a decade.
Incredibly effective, dramatic drop in types 6, 11 incidence rates since vaccine introduced. Now we are seeing a decline in high grade abnormalities (CIN grade III, carcinoma in-situ).
National cervical screening program: 2-yearly PAP test for women aged 18-69 years.
Uptake: 2-yearly 58%, 5-yearly 83%.
Effect: 50% reduction in incidence and deaths from cervical cancer.
80% of cervical cancer in women in Australia occurs in women never screened or under-screened.
New cervical screening test will be implemented from May 2017.
Why? - newer technologies (HVP tests and liquid based cytology), allowing us to target more risky lesions and test low risk lesions less frequently reducing cost, while at the same time predicted to reduce cervical cancer cases by 30%.
Primary HPV test with partial genotyping (HPV 16/18 DNA/RNA PCR), alongside liquid based cytology (LBC), i.e. two screening tests in one.
Five-year screening interval because of lower risk of progression to significant disease within that period.
Starting at age 25 years, up to age 74 years, because of a very low risk of disease < 25 years and that surveillance in this group has had no impact on survival.
Self collection is an option (just tests for HPV PCR, need to recall patient if positive for physician to take a swab for LBC, may reach those never screened or under-screened).
Still need a speculum vaginal examination but 9 in a lifetime rather than 26.
New terminology - Lower Anogenital Squamous Terminology (LAST):
HSIL - high-grade squamous intraepithelial lesion (CIN II, CIN III).
LSIL - low-grade squamous intraepithelial lesion (consistent with HPV infection).
SISCCA - superficially invasive squamous cell carcinoma.
Squamous cell carcinoma.
The test is reported:
High risk - HPV types 16 or 18 are detected regardless of liquid based cytology.
High risk - HPV types other than 18 or 18 and HSIL.
High grade lesions are referred for colposcopy.
Intermediate risk if HPV types other than 16 or 18 and LSIL.
Intermediate risk is screened annually.
Low risk - HPV not detected.
Low risk is screened in 5 yearly intervals if immunocompetent. “Immunodeficient” (CD4 count < 400, unclear what this means for those on immunosuppressive therapy) - screened at 3-yearly intervals.