This presentation by Doris Chebo looks at the risks of the change of thinking towards pushing for treatment as soon as possible after HIV diagnosis from the point of view of current Victorian baseline HIV drug resistance profiles .

The aim of earliest possible treatment is to limit risks of disease progression and reduce HIV transmission, both very worthwhile ideals .

Levels of transmitted drug resistance mutations were reviewed looking at standard drug resistance genotyping in 1356 samples from 2011 to 2015. These included new 

As expected, protease and integrate inhibitor regimes had the lowest level of potential resistance (<1%). Potential resistance to NNRTIs was higher at 4.6%.

This brings up the question of whether to start people on treatment before genotype profiles are available particularly where access is more difficult.

The study was pretty reassuring for us, in that these seem like only  small number of patients had significant drug resistance to our usual ASHM recommended first line treatment regimes.

 

James McMahon  presented  a study comparing HIV load and CD4 count for people in regular care versus those   with unknown outcomes.

He estimated the study covered 80% of HIV positive patients in Victoria over 3 years in 4 sites.

It involved clinics checked their records to look for transfer of care, deaths and returnees to care. 

Patients who did not return for at least one more VL  within a 9 month period were then contacted.

Retention rates for patients were very good at 92%. 

The study found that those who had unknown outcomes,transfered their care/returned to care or who had irregular VL testing had higher VL and were at risk of worse clinical outcomes and onward transmission.

They found that as a result of doing the study there were improvement in clinic systems to improve retention and keep patients engaged in care This was an unexpected positive outcome from this study.

 

 

Amber D'Souza outlined the epidemiology of anal cancer pointing out the significantly elevated risks for HIV positive MSM. She found DARE acceptable to patients within a study of 327 men.

Dr Jason Ong posed the question "What should we be doing with our patients now?"

He gave compelling reasons to screen for anal cancer targetting the most at risk, that is HIV positive men > age 50 ideally with an annual digital rectal exam to try and detect anal cancer at an earlier stage than is currently achieved with reactive checks related to symptoms.

50% of anal cancers are visible externally ie just looking would make a huge difference and currently less than 10% of HIV positive MSM have annual anal exams.80-100% will be found with DARE.

It is a simple safe cost effective and acceptable practice and can lead to better outcomes.

The evidence for screening for precursor lesions seems less compelling. 

HSIL is present in 30-50% of HIV positive gay men however only 1/400 progress to cancer in HIV positive men and 1/4000 progress to cancer in HIV negative men. 

SPANC has greatly increased understanding of this process.?Highest risk to progression to anal cancer is seen in those with persisting HPV16.

It was also suggested by Jason and Dr David Templeton to consider HPV vaccination in this group as despite the lack of evidence for efficacy, it may work.

From positivelife NSW we learned that most PLHIV  thought their risk for anal cancer was the same or lower than the general population.

84% of respondants in that survey and 64% HIV respondants had never talked to thier doctor about anal HPV/cancer- we should clearly be doing better than this.