Dr Jason Ong:Monash Uni,The Alfred,MSHC

On Prevention of Anal  Cancer in Gay and Bisexual men:the current state of play and future directions

Excellent series of sessions

This session highlighted that we must reflect on some of the changing practices of rapid testing ,increase testing ,self  testing and remember the need for clinical examination also: LOOK

HPV VACCINE :THE GAME CHANGER

But a cohort has missed out

Do we adopt cervical screening protocol and do "chap smears"

Highlighted the key difference with anal Ca and cervical Ca although both SCC

Anal pap larger area,harder to identify lesioms in a collapsing environment,

Differing natural history

Differing referral rates,massive need for HRA/not feasible

No one agees best approach

Still no proof treatment assists outcome

.?trace the 30% males with HGAIN

Need better ways to treat,more RCT havent the specialists

Greater than 50% Anal Ca externally visible average lesion 2.9cm HUGE

BUTLess than 10% HIV  MSM  have annual anal exam

Need early Ca detection model:less than 2cm lesion possibly just excision with no spread or sphincter involvement,no chemo or radiation

Implement anal digital

Based on Wilson and Jungner screening critera 

;"GIVING THE FINGER TO ANAL CANCER"his PhD title

Key findings ;all specialists think it is important to screen for anal Ca but arent doing it

www.anal.org.au/clinician MSHC;:

Annual DARE study and recommendations

Acceptable,minimal s/e

99% clients willing to have annual dare

Dare is cost effective,safe,acceptable

TIME TO Do DARE translating evidence into action

Summarised;

Screen for precursor lesions

Triage

RCT FOR DARE unlikely

Jason is running an educational session at the ASHM hub Friday

DO YOU DARE?

Timely as Tasmania Sexual Health are  fortunate to have Prof Richard Turner:Colorectal surgeon Royal Hobat Hospital/UTAS

Continuing his research with monitoring HSIL anal paps :HRA ,histology ?treatment for HIV clients and Women with HSIL paps

He has spent time to demostrate DARE  to all clinicians and advises annual DARE

The final session by Brad Atkins of his horror story of his  diagnoses and treatment of anal cancer and being totally uninformed and underprepared and to be reminded of the STIGMA,embarrasment people feel

Makes it urgent to "AT LEAST LOOK AND PUT YOUR FINGER IN OR YOU WILL MISS IT"

BACK TO THE BASICS.....

Satellite Session:

Fantastic expert  panel presentation informally discussing reality of target and inviting audience participation

Consensus a Challenging target

Possible to eliminate as Public Health threat if role out of new treatment continues

Treat as prevention to decrease new infections

Do need vaccine as resistence possible

Possibly Realistic target have the tools, systems, funding

Need to ENGAGE people

Large population of HCV , it is not their priority

greater 40,000 treated  by end year but  many still not aware treatment availability, also ageing population

Need GP's to take up treatment

need to test, need good history taking ,use database

Remember STIGMA prevents accessing GP

need to increase training for GP's in Hep C and treatment

Open treatment landscape

Move out of Hospital specialist, GP could  use if not got skill set

Target will need massive investment for Aboriginal Medical Services

15-24 ages :Indigenous 8x higher Hep C rates

Increasing IVDU under acknowledged

And Prison

Will need sysrems to monitor who is on treatment

think treatment as prevention, frame positively, can cure

Solid plan to include Primary care, main contact point for Indigenous population

HIV coinfected treat early,  care re reinfection but Caution STIGMA

Remember DDI, be aware

HCV and HIV VL not an issue

BUT noted easy for the experts to say  need to role out updated info and guidelines for GPs

Reinfection main risk Prisons

Discussion around barriers to OCT (opiod substitute therapy/methadone)

Difficult to access in prisons....THE DIFFICULT area despite funding

NEED SAFE INJECTING PRACTICES and regulated needle exchange

30% Indigenous in prisons including youth

SA making inroads re strategy

Reminder Indigenous mobility 

Suggests Research grant re what it would take to get to target in Indigenous population

Cairns area low IVDU BUT caution change

Prison Mareeba attitude to treat prompt and often

Remember to look GLOBAL

Reminder of costs and increasing problem crystal meth

Problem HePC treatment still mainly metropolitan area

Need strong GP networks

Resistence in initial HCV regimes not a problem if Fail may need 2nd line

Need traditional Public Health approach

Indigenous population need treatment as prevention and to hear benefit of cure

Discusion re HIV group take on HCV as experienced

Need to be realistic, limited specialists,liver clinics problematic

Use of NPs

Need to be able to write prescriptions....in the pipeline

Overall consensus came at role out was backwards

Ivory Tower Not as Public Health problem

Approach should have been: 

ASSUME population dont know

Hep C much more prevalent

GET tested

Treatment can cure

Access to clean needles

Implement systemic changes in Primary care

Who are pos

Who is on treatment,adherence

Chronic care plans......

Overall great opportunity to see where the new treatment role out is at with a target date set for HCV elimination...

and opinions at what needs to be done 

Highlighted the continuing shame to ignore Indigenous population requirements, 

We once promoted safe injecting,needle exchange....

The title Australia leads the world is not deserved until it is truly inclusive to its Indigenous population needs

Plenary 2 Tuesday 15/11/2016

GOLLOW LECTURE :Rebecca Guy Assoc Professor Kirby Institute:surveillance,evaluation and research program

Presented new technologies for STI  Prevention

Re thinking Sexual Health 

And how can we use new technologies for disease prevention

Specifically Information technology

To embrace what people are using therefore currency

In a world open 24 hours

Primary and secondary prevention:STI testing and diagnoses

What technology has been evaluated

PROBLEM: STI Testing;time consuming/registration 

Solution electronic client self register:self appoint

Outcome evaluation significant benefit re time saved

Problem of awkward conversations 

Solved by computer assisted survey instrument (CASI) 

Linked with management system

Evaluated as efficient, acceptable,

Problem of STI test with clinic capacity

Solution Xpress clinic

Evaluated 

All leading back to reflection and constant need to improve efficiency of practice and improved outcomes for clinic and client

GP still low STI  testing rates despite 80% young people go to GP

Latest findings suggest poorly targeted

ACCEPT survey:

150 GP clinics

73.4% of chlamydia presentations asympto clients attending for non sexual health issues /missed opportunistic test

.? COMPUTER PROMPTS 

Evaluated and helpful 30% increase testing

Need comprehensive screening eg previously rectal swabs not done MSM

User friendly software

Low Syphilis   testing in increasing STI rates

Solution:opt out/opt in syphilis test in HIV management

Simple cheap study in 2007 by DR Melanie Bissessor and MSM with HIV

Simple sticker on file requesting syphilis check

Pre 21%

Post 85% :such simple cheap intervention.

Study 2

Syphilis testing same day as HIV VLautomatic,could deselect:

Colaboration required clinics, labs under Burnett Istitute

ACCESS checks how tracking

Generally need to increase testing rates

Problem of treatment delays especially Remote areas

Discussed SMS reminders recall possibilities

TTANGO (test treat and go);Colaboration 12 Health Services

Key message is the mean time to treatment

With POCT 4/7

Lab test 19/7

And partners to be treated

Use of "Let them know"websiteMSHC, evaluated/acceptable:SMS

BUT people not returning TOC, reinfection and dangers PID etc

Discused other clinical strategies and efficiency eg: REACT RCT:

Not suitable for test kits mailed to address parents,partners

Other technologies not comprehensively evaluated

WA online educational resources parents and adolescents

Poor condom use reported: Adolescents report "no condoms it just happened"

The new world of online websites to meet and connect and how to tap into that population group to encourage testing

The difficulty of behavioural interventions

Technology must help research ,rapid info to inform  progress

data.kirby.unsw.edu.co JUST released

TAKE HOME MESSAGE

Why not all Health Services using IT/online technologies 

Is the future online Sexual Health Services.......

Need to all look at improved, efficient, acceptable and cost effective ways of increasing comprehensive STI I testing

Christopher Fairley  MSHC presented

The use of nformation technology to improve Sexual Health care in a following session

Which complimented Rebeccas presentation

Great comment; Health care is most important fight against STI

STI easier to control than treatment

Sexual Health does not deal with "noble organs" does not attract the $

need to be more efficient....like the Banks....

Need IT in clinical services

CAS:I :all staff  and clients love it

Use of SMS

Websites like Let them know

STI Atlas

Whats PREP

DATA OPENS EYES

CLINICIANS NEED TIO UNDERSTAND DATA

NEED A DATA BASE

Opening plenary was powerful  and a good example of the need for constant reflective practice:

with Khadija Gbla's ;

Discovering Sexual Health from a CALD perspective, addressing Sexual Health as a Human right, the need to reach out to all, LGTB et all, the need to be all inclusive

SexualHealth as a Western construct and the need to unpack that

Information is power!

The need to for currency of practice

Basil Donovan as ASHA Distinguished Service Awardee

Reflected on the past differing approaches by Family Planning,Sexual Health and organisations and how finally Service providers with ASHA are uniting  resources

Basil reflected on the need for the community to be more involved centrally

 the new shared  STI guidelines

the past work to decriminalise CSW

Looking back to the AIDs fear from 1983 

His early  Lancet articles and their timeliness

Indigenous Health review

Increasing POCT

ACCESS SURVEILLANCE :50 CLINICS Monitoring National trends and problem solving

The introduction and massive impact of the HPV vaccine: which carried through the days HPV presentations

The syhilis outbreak in Remote Australia

and the work needed ie chlamydia and less than 1/4 diagnosed

His message was TIMING is better than data

Again that strong message of ensuring reflective practice, and currency of practice

The plenary then aunched into all about HPV; oral to anal

Amber D' Souza; Rethinking HPV and Related Disease prevention

The changing epidemiology of HPV

Despite the HPV vaccination still greater than 5% of global cancers

Mindful that Australias HPV vaccination roll out and screening programme remarkable with 71% vaccinated zand acheived a herd immunity

UK 60.4%

USA 33.4%

Now evaluate to be able to continue in light of cost effectiveness 

Reseatch shows Number of vaccinations required for same HPV Ab response ;probably  2

What resource poor countries could use as rollout

The look at female and male vaccination in light of Public Health and cost effectiveness

Oral HPV 6x more common in males

Oral sex with females Increasing risk factor

.? HPV VL higher in cervical fluid than on penile shaft

Or reduced immunity

Males less likely to clear infections

But that sexual behaviour does not explain differnce re sex and HPV incidence

Marion Saville The National Cervical Screning Program; On the Cusp of Change,giving a VERY comprehensive overview on the new guidelines post the introduction of Gardasil in 2007

Giving caution of a global overview regarding discrepancy in surveillance between countries

Aust surveilance good

National Register for vaccination

High school coverage

GPs under notified older women

Still work to do in Indigenous and CALD communities as a continuing theme

Lowest 10% socio economic not getting to school

Safety of vaccine

Evidence of high levels Antibody response probably sufficient for life

Now vaccination offered to prevent secondary recurrence HPV

Looking at the 2 dose schedule

USA 9 valent vaccine approved

Hard to measure success, more adjuvent more pain

Probably will be the same in future for Aust re cost effective

Outstanding success cervical screening program

BUT Took 40 years from pap to be recognised as imporant scrreening tool

Frazer and HPV vaccination

But now need to address EQUITY

Modelling suggests 30% reduction cervical cancer on top of vaccination

Outlined new guidelines with new technologies

Self collection

Caveat no change to incidence adenocarcinoma only squamous cell Ca

Discussed quality improvement and COMPASS Trial

Carried through to afternoon session Clinical Sexual Health and Epidemiology:Anal HPV

And non clearance of Anal HPV in males esp HPV16 increased with age

No difference if HIV

2 HPV tests at least 6 months a part may identify male with persisting chronic HPV and the increased risk of Anal cancer

screening moving to HRHPV testing 

Ongoing research toward cost effectiveness and best practice and equity...