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.
As my patients are almost all women living with HIV and from an African background who are very keen to breastfeed, this session was number one on my priorities to attend despite being yet an another 7:30am presentation.
The presentation was set up as a debate with three speakers although in the end, they all came to a similar conclusion!
First was Dr Karoline Aebi-Popp (Obstetrician & Gynecologist (German Certification), MSc Infectious Diseases – Specialized in Sexually Transmitted Diseases, University Hospital Bern,Switzerland) who presented the ‘no’ side to the question of whether all women is Europe living with HIV should breastfeed.
Worldwide, 150,000 child acquired HIV in 2015 and 1/3 of these acquired their infection from breastfeeding. Karoline did point out that most of this data is African data. Although ART reduces the HIV RNA levels in breastmilk it does not reduce the HIV DNA levels. There is also evidence that some of the ARTs get into the breastmilk such as dolutegravir which has a number of potential problems.
There is a risk of resistance if the infant is exposed to monotherapy via breastmilk. Also there is a risk of delayed diagnosis if the baby is positive but ART suppresses virus replication.
Overall from meta-analysis of all evidence of breast feeding in HIV, the risk of MTCT ranges from 0.9%-4%. Is this acceptable given in high income countries we have access to a safe alternative which has a 0% risk of MTCT?
Dr Fiona Lyons (consultant in Genitourinary and HIV Medicine at the GUIDE clinic, St. James’s Hospital, Dublin, Ireland)spoke next on the ‘yes’ side supporting breastfeeding in maternal HIV.
Fiona made the important point that we need to not just look at MTCT but also benefits of breastfeeding for the mother including breast cancer reduction. She produced evidence that MTCT in an ideal world is less than 1%. All the evidence we have about breastfeeding in maternal HIV Infection includes low and middle income countries which may not reflect the potential in high income countries with safe access to bottle feeding and high quality HIV care and follow up.
She emphasised a patient-centred approach with an individual assessment of each patient and their circumstances.
Dr Karina Butler O’Connell (UCD Clinical Professor of Paediatrics, Consultant Paediatrician and Infectious Diseases Specialist at Our Lady's Children's Hospital and The Children's University Hospital, Temple Street, Dublin, Ireland) spoke on behalf of the child. She presented the evidence that in low and middle income countries breastfeeding actually decreases mortality due to reduction in diarrheal diseases. However even in high income countries, the MTCT rate was not zero. This risk goes up when we look at actual behaviour not just ideal behaviour (reduced adherence to medication, lost to follow up etc). For the child, she felt this was not an acceptable risk.
I look forward to the prospective cohort study that Karoline is involved in looking at transmission rates in breastfeeding.
- have an individualised approach
- Better to allow the mother to discuss in an open environment.
- We need more research particularly around models for supporting breastfeeding
Below is a link to Lancet review and discussion of evidence in HIV and breastfeeding.
I found this session particularly good and relevant to my practice. I also ran into my mentor for HIV prescribing Dr Olga Vujovic from The Alfred hospital in Melbourne at this session which was great!
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:
Ischaemic heart disease 150.5
Maternal conditions 148.4
Breast cancer 130.9
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.
There was a flavor of dual therapy around Mondays Plenary. An interesting study for Australian audience was the ACTG A5353 study which is a pilot study of Dolutegravir + lamivudine for the initial treatment of HIV-1 infected individuals with viral loads of less than 500,000 copies/mL. The 24 weeks data was presented using the FDA snapshot definition. There were 120 participants with no baseline resistance identified. There were no discontinuations. This regimen demonstrated potent virilogical efficacy at 24 weeks. 3 patients met the criteria for a protocol defined virilogical failure (PDVF), one had emergent M184V.
The other interesting update was the 48 week data for Bictegravir(B)/F/TAF vs. ABC/DTG/3TC. This is a phase 3 RCT for treatment naïve adults. The primary endpoint HIV-1 RNA < 50 copies, powered for non-inferiority. B/F/TAF was non-inferior at 48 weeks. It was well tolerated and there were no adverse events leading to discontinuation. Nausea was significantly greater in patients taking ABC/DTG/3TC. Gastrointestinal, Neuropsychiatric and sleep related problems were also more common in the ABC/DTG/3TC patients. Changes in BMD and renal function were comparable. The speaker felt that B/F/TAF was an “attractive” option for rapid commencement of antiretroviral therapy as no HLA status is needed and it could likely be commenced irrespective of Hepatitis B status and renal function.
I am reporting back from the IAS2017 session Mind the Gap: Filling knowledge gaps in Paediatric and Adolescent HIV for an AIDS free generation -- the first satellite session at 8 am on Sunday morning, well attended with standing room only.
This satellite, organised by the Elizabeth Glaser Pediatric AIDS Foundation will launch the research agendas and discuss considerations emerging from the process such as the use of observational data, optimising clinical trials design, the roles of basic and implementation science, and the role of community engagement, with a focus on the meaningful engagement of youth.
As a General Practitioner previously involved with youth sexual health screens in North Queensland where there is a relatively large proportion of teenage patients, I found this session quite useful.
The most useful discussions were personal anecdotes by the speakers and from questions asked by the audience.
One question was asked to Carlo André Oliveras Rodriguez from Adolescent HIV Treatment Coalition (ATC), Puerto Rico, regarding the use of non-monetary incentives. He described using transport and internet access as alternatives.
I have myself seen the impact of using monetary incentives as impacting on future testing and treatment and it was great to get alternatives.
The delegate next to me, from the London School of Hygiene, said that ethics committees strongly restricted them to the use of food and drink or transport only for incentives.
There was a flyer in my welcome pack for a program in the United States called the Undetectables which also touched on incentives for maintaining an undetectable viral load.
Visit the website: www.liveundetectable.org
The discussions were mainly in the context of research but I would like to transfer this knowledge to youth engagement in primary care such as a youth drop in clinic.
They also discussed barriers such intellectually disabled youth and hearing impaired such as youth officers trained with this in mind.
They talked about some young people preferring twice daily smaller pills rather than once daily larger sized pills. But also that the options for treatment of younger people with low body weight were a barrier due to limited single pill combinations.
The Elizabeth Glaser Pediatric AIDS Foundation host again another satellite session this afternoon with the goal of the satellite to raise awareness and facilitate discourse regarding adolescent-specific needs as a part of a comprehensive national HIV/AIDS care and treatment package.