Findings from the national online HIV self-sampling service in England. (Luis Guerra).

I found this talk to be if interest because in NSW we have launched the Dried Blood Spot - Home HIV self testing.

In England - eligible participants go to a website - WWW.freetesting.hiv and answer a. Few questions and then get a box sent the address they register.

The person then follows the instructions in the kit and utilising a lancet leaves a blood spot which is then posted back for testing.

Results are then sent out within 3 days via the delivery method the participant chooses.

If the result shows Reactive - the participant is contacted via phone and notified of the Reactive result - explaining the possible outcomes of a reactive result (Explaining it doesn't mean its a positive test).

The participant is given the details of local clinics and services and offered an appointment or they are able to book themselves.

Of the 40726 kits sent out - 22085 were returned. That's a 54% return rate.

There were 239 reactive samples.

Of those that tested 30% had never had a test. And 32% last tested over 1 year ago.

I hope that the NSW Dried blood spot testing program has such a high return rate and that we are able to capture the amount of people that otherwise would not have tested.

This morning I watched a presentation by Joshua Rosenberger (USA).Examining the role of STI prevention among MSM using mobile applications.

He was discussing a study that was conducted in a American city with a population of about 1 million people. Looking at how many MSM that logged into a particulat Geospactial networking app within a 24 hour period.

And where these men lived in relation to the Sexual health and HIV services that were available in the city. 

In a 24 hour period 5000 men logged into the Application. Most of the men being of white or Hispanic background and living in the inner city and downtown area. There was a population of African-American background that lived further on the outskirts of the city. The peak time for log on being 2000 through till 2300.

Using this information and location of the men that logged in they could see the centres for access (their clinics were all located in the city area). Which was great for the small population of white men that lived in that area. But not so for the rest of the population. Especially there most at risk men of African-American background. 

The clinic hours extended until 1730 at the latest. So how could they use this information for health promotion and to allow for better access to the rest of the population at greatest risk for STI/HIV prevention and education?

My Take HOME MESSAGE:

Harnessing the use of mobile application services is a great way to ascertain where the target population are living and using the platforms for advertising "Health Promotion".

In Australia and especially in NSW we have embraced Mobile Social Applications such as GRINDR to deliver Health promotion activites. But can we better utilise the data to look at where we need to direct outreach services to capture the proportion of the population that do not live in "The bubble" of the innner city - where a lot of our Sexual Health and HIV services are located. 

Today I watched Catriona Bradshaw (Monash University, Melbourne) present on M.G.

WOW. Great presentation.

M.G Slow to grow and difficult to culture. 

Looking at resistance patterns around the world its very clear that over prescribing of Azithromycin has lead to macrolide resistance in M.G.

Looking at countries that have prescribed STAT Azithromycin for NGU and now looking at resistance profiles its very evident that we need to change our thinking and prescribing.

Catriona showed the resistance profiles of two countries side by side - Sweden and Norway. One Country having used Azithromycin in NGU treatment and the other having used Doxycyclin. Very different results.

It made me think of the landscape in Australia - and the different drugs being used in current guidelines. Which I might add are always evolving with new evidence.

Russia has a low prevalence of resistance - Its not used Azithromycin.

Countries that have used Azithromycin in NGU have had an increase in resistance from 10% to 40% in 10 years.

Widespread use of Azithromycin for STIs and Syndromes has led to high failure rates for M.G.

Some regions already leading the way - U.K. And Europe changing guidelines to recommend Doxycyclin.

We need to move towards testing that can perform resistance testing so treatment can be individualised.  This will shorten the duration of infection, reduce transmission of resistant strains and recurrent clinical presentations.

Gwenda Hughes (National Centre for infectious Disease Surveillance and Control at Public Health, UK)

Spoke about some STIs that are neglected or under tested for. Primarily she spoke about Trichomoniasis. LGV and Enteric Infections.

TV - Seen very rarely in Australian population - but are we testing enough? A large poprtion of infections are asymptomatic. With a higher prevalence noticed in African and black women in the UK.

LGV - Endemic in Africa, Latin America and Asia. With small numbers seen in North America and Australia.

Recently there has been a resurregence in the reported cases in Europe with 25% of cases in the UK being asymptomatic and 50% of cases in Germany being asymptomatic. 

Germany also found that of the positive CT results in MSM 17% of rectal infections were LGV positive and 15% of throat infections were positive for LGV. I found the throat infections very interesting.

Entric Infections - Shigella, Hepatitis A, Giardia.

Outbreaks in MSM population in the UK - found to be higher in MSM that participated in Sex parties, Chem sex (slamming) and HIV+Ve practising CLAI. Are we missing these infections. We routinely test for Hepatitis A in our MSM population and we have great programs for free vaccination of Hepatits A. But shigella is not routinely tested for and requires testing of stool samples. 

Point of care testing - is it the way of the future? Dr Tarim Sadiq (St. George's University of London) Spoke about new POC testing technologies currently used and some that are in the pipeline of development. 

Dean street Clinic in London are currently utilising the GenXpert POC tests where results are available in 90 minutes. However most clients do not want to wait in the clinic for 90 minutes. Available now and with more in the pipeline are a new generation of POC tests where results will be available in under 30 minutes. Meaning that clients can receive treatment at the initial consult if they have a positive test result. 

In the not to distant future POC tests that can test for CT. NG. MG and TV will be available. And resistance testing for NG and Macrolide resistance in MG will be available in the POC Tests also. 

So what are the barriers to implementation of POC tests. And is there a space for their use in Australia. 

Firstly the COST - In Australia in the sexual health clinic setting we have access to tertiary hospital laboratories. Do we need to outlay more money for POC tests to be available  in the clinic setting?

And what are the public perspectives in relation to POC testing - are they open to the idea of using POC tests or do they want conventional laboratory tests thinking they are more accurate?

The talk at the conference is that POC tests are the way of the future, How we integrate them into our practice is another question.

The exciting thing that I believe comes from POC testing is that resistance testing for STIs will be available quickly meaning the right medication can be used first go. 

Thoughts? 

This morning saw the kick off of the STI and HIV World Congress in Rio de Janeiro Brazil.

First off this morning was the 2016 WHO Treatment guidelines - last updated in 2003.

Noting that the new guidelines will be released in 3 stages.

(A.Prof, Director) Magnus Unemo of Swedish Reference Laboratory

Neisseria Gonorrhoea:

Treatment recommendations for Dual therapy over single therapy.

Ano-rectal and UI-

- Ceftriaxone 250mg and 1G Azithromycin 

- Cefixime 400mg PO and 1G Azithromycin.

Oral N.Gonorrhoea-

- Ceftriaxone 250mg and 1G Azithromycin.

- Cefixime 400mg PO and 1G Azithromycin.

It's of importance that currently in Australian Guidelines 500mg of Ceftriaxone is recommended and the WHO recommend 500mg in it's 2nd line treatment when 1st line therapy has suspected treatment failure.

Representitives from the UK and Europe also stated that are currently using 500mg as first line therapy due to high prevalence of resistance.

Dr Nicola Low (University of Bern)

Chlamydia trachomatis 

Take home message- changes in guidelines

- Use of Doxycycline over Azithromycin for Ano-rectal infection.

- 100mg Doxycycline BD for 7 days.

LGV - Treat with Doxycycline 100mg BD for 21 days - was 14 days in previous guidelines. 

Dr Francis Ndowa (Zimbabwe, WHO consultant)

Syphilis

Primary, Secondary and Early latent (2 years or less)

Treatment is with (2.4 million units) 1.8g Benzethine Penicillin IMI Single dose.

Alternate Treatment - Procaine 1.2 IU IMI Daily for 10- 14 days.

Late Syphilis (more than 2 years)

Treatment is 2.4 Million units Benzethine Penicillin IMI one dose one week apart for 3 consecutive weeks.

In penicillin Allergy - 100MG Doxycycline BD for 30 days.

Dr David Lewis (Sydney, Australia)

HSV

19.2 Million new HSV infections in 15 - 49 year olds world wide in 2012.

Recommendation 1 - 1st Episode of HSV infection - treat.

Recommendation 2 - Treatment recommendation Use Aciclovir over Valciclovir or famciclovir.

Dosage 400mg TDS for 10 days.

Recommendation 3 and 4 - Recurrent symptoms treat within 24 hours of symptoms or prodromal phase with Aciclovir 400mg PO TDS for 5 days, 800mg BD for 5 days or 800mg TDS for 2 days

Valciclovir 500mg PO BD for 3 days.

Recommendation 5 - For recurrences of more than 4 per year consider suppressive therapy for 1 year and then reassess. Aciclovir 400mg BD for 1 year.

Dr Manica Balasegaram (Global Antibiotic Research and Development Partnership, GARDP)

Spoke about the development of new treatments for STIs and in particular showed a snap shot of a road map for development of new treatments for N.Gonorrhoea with the main goal of new treatment by 2023.

Main goals of accelerating new agents to be used and investigating existing antibiotics that could be used in new combinations. It's exciting to see that we are looking to the future in regards to Antibiotic stewand ship and treatment of emerging resistance.