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. 

BBetween sessions I had an opportunity to view some posters highlighting excellent research from around the world. I was happy to see some findings from PrEPX in Victoria:

Sexually transmissible infections as HIV risk markers at baseline in PrEPX, a large Australian PrEP trial – An analysis of formal eligibility criteria; Dr Vincent Cornelisse (Prahan Market Clinic, Melbourne) concluded that participants who were enrolled despite not meeting eligibility criteria still had substantial prevalence of STI’s (7.1%) which suggests that someone requesting PrEP is likely to be at considerable risk of HIV, even if they do not meet the eligibility criteria.

Comparison between HIV risk reported by clinicians and HIV risk reported by participants at enrolment in PrEPX, a large Australian HIV pre-exposure prophylaxis study; a finding of this analysis showed that patients may over-report CLAI with HIV + receptive sexual partners to their PrEP providing clinicians, but under-report methamphetamine use and CLAI with casual partners.

There were 2 interesting posters on smartphone app use to reach target populations. This research builds on what we learned earlier in the day’s plenary sessions about utilising low cost technologies where possible in resource poor environments:

Understanding the Impact of Smartphone Applications on Sexually Transmitted Infections (STI) and HIV prevention among Men who Have Sex with Men (MSM) in the EU/EEA, highlighted that smartphone apps are currently under-utilised and that realising their potential requires support, engagement, and coordination from EU stakeholders and engagement with the private sector.

Harnessing the Power of Smartphone Dating Apps and Online Tools to Increase MSM testing in Europe and Central Asia through a Community, Business and Public Health Partnership, described a partnership between 3 smartphone apps (Hornet, Grindr and PlanetRomeo), the ECDC and European HIV/Hepatitis Testing Week where the apps provided free advertising to promote a site with information about testing sites across Europe and Central Asia (European Test Finder). The app pushed out information to millions of users in 40 local languages in 53 countries resulting in 65,614 hits. This demonstrates the power of partnerships between public health and private sector business in improving access to education about testing for HIV.

Dr Anastasia Pharris from ECDC in Stockholm gave a detailed and insightful presentation on the state of HIV in Europe.

Current situation 

• Globally HIV incidence is decreasing due to ART and viral suppression, but Europe is still increasing, mainly in the east
• 80% of new HIV infections in Europe in 2015 were in Eastern Europe and mostly attributable to IDU but this is declining over time
• MSM may be under-reported in the East
• Mother to child transmission is very low in virtually all countries

Is Europe's response to HIV sufficient?

• Probably not as many people are diagnosed too late
• There is a big move now to test and treat regardless of CD4 but in undocumented migrants this falls short
• Viral suppression is achieved in many countries, but Russia and the East are well below targets

Challenges and opportunities moving forwards

• Europe needs to implement what they already know works
• Harm reduction coverage remains low in parts of Europe and should be improved
• Changing the culture of testing to community based, home sampling and non-medical staff will expand in the next 10 years
• Many countries are still on the fence about PrEP, particularly in the East
• 2/3 countries in Europe report that funds for HIV prevention are insufficient to implement the necessary prevention strategies
• Low cost interventions should be utilised to target populations at risk e.g. Health promotion through apps (I will discuss an interesting poster about this in a later post)

Stigma remains an issue and Europe is not addressing this adequately

This was a very interesting discussion and there are points to consider in the Australian context – the use of mobile technologies and partnering with the private sector in this space; maximising access to harm reduction strategies as we know this works; and looking at expanded opportunities for testing outside the medical model to engage high risk populations.

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. 

Hello from the 16th European AIDS conference in Milan. 

This morning I attended a very interesting workshop organised by WAVE, Women against Viruses in Europe, where numerous aspects of caring for women with HIV were presented and discussed.

The session started with a very powerful and insightful presentation by Justyna Kopec who has just celebrated her 20th anniversary of living with HIV. She discussed her journey to diagnosis and disclosed a number of lost opportunities to an earlier diagnosis (eg testing and then never returning for results) and highlighted that staff at her 'clinic' were integral to her feeling supported throughout her life living with HIV. This was a really excellent presentation to kick off with to remind us all to keep patients are at the centre of their care.  (see Catherine Orr’s notes from this session here)

Following was an analysis of the models of care for HIV positive Women in Europe split into West, Central and Eastern areas by Dr Annette Haberl from Germany, Dr Cristiana Oprea from Romania and Dr Inga Iatysheva from Russia, respectively. There is a huge amount of detail surrounding the variations in HIV care in each country and all face similar challenges in varying degrees i.e. coordination of allied specialist services such as gynaecology, psychology and social supports, or lack of integrated services, particularly in less economically enabled countries; barriers to accessing care surrounding child care responsibilities; lack of gender autonomy; fear of stigma. 

I noted that nurse led models of care for women living with HIV did not come up in discussion from any of the 3 speakers; the analysis may have not drilled down to this level but nurse led models of care could be useful in resource poor environments particularly. Additionally, further research as a high priority area was raised, and 2 speakers suggested that WAVE could be the right platform to assist coordinate research, exchange experience and create expert advisory groups.