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:

HIV 241.9

Ischaemic heart disease 150.5

Maternal conditions 148.4

Stroke 139.5

Breast cancer 130.9

Tuberculosis 96.4

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.

 

 

 

Day 3 of the conference and PrEP of course has been the 'hot topic'

This oral abstract session was a reminder that there is more to prevention than antiretrovirals however.

First up, Kelly Kilburn gave evidence from the HPTN 068 study in South Africa where a third of women experienced physical violence by a partner. And there are direct correlations between this and HIV transmission.

The experiment involved 2,533 women between the ages of 13 to 20 years. They were randomly assigned to one of two groups where one group of girls (or their parents) received approximately $10 USD if they attended at least 80% of school days in the past month. Participants then completed a self interview and HIV and HSV-2 test each visit and at 12, 24 and 36 months following. The questionnaire was able to distinguish between sexual and physical intimate partner violence (IPV). 

The conclusion was that the conditional cash transfers had no significant effect on sexual IPV, HIV or HSV-2 acquisition. There was however a significant risk reduction for physical IPV by 34%. It was interesting to note that there was 95% attendance in both arms of the study and that the cash payment had no effect at all on school attendance but may have given the young person the independence from a violent intimate partner. 

I took a few interesting points from Shona Dalal of the World Health organisation that will be useful to my practice. She presented a systematic review of HIV partner notification services. Assisted versus passive notification where there were varying types of active notification - contract, provider or dual referral approaches. Contract is where the HIV positive client enters into a contract to disclose their status within a certain time frame and advise their partner to have HIV testing. Provider is where the provider confidentially contacts the HIV positive clients partner and offers voluntary testing. Dual referral is where the provider accompanies the HIV positive client to assist whilst they disclose their status and voluntarily offer HIV testing services.

With all types of notification if it didn't occur within a week it was less likely to occur. There were very few reports of harm and there was increased linkage to care and treatment among partners.

There was a talk from Sean Allen regarding a change in the policy of syringe distribution in Baltimore, MD from 1 syringe given for 1 returned to as many given as required. The number of syringes distributed doubled but the average number of HIV infections per month reduced. 

Also covered in this session were male circumcision and its effect on transmissions to women of sexually transmitted diseases. And also community based distribution of oral HIV testing kits aiding the early diagnosis and treatment of men in Zambia. 

Phew - what a session!

 

I attended this one hour punchy poster discussion session on Monday lunchtime. It covered a wide variety of topics including cardiovascular, renal, lipids and brain function, chronic pain and mental health in people living with HIV. It included an Australian presenter Dr Nicholas A. Medland who concluded that "Fanconi syndrome occurs at a late stage of antiretroviral treatment" and that it is "an uncommon but not rare" outcome. That "Ritonavir use increases the incidence by 5 times". And there was a memorable point to take away that monitoring is important and simple (once to twice a year urine dipstick test) even in long term patients who do not appear to be at increased risk.

Following this there was a talk by Dr Felicia Chow regarding higher HDL and improved brain function. There were 988 participants in the study and 80% were male. 27% were taking a statin medication and 36% an antihypertensive medication. I could relate to the frustration behind the questions from the audience regarding what can you actually do to increase HDL levels. As getting active, losing weight, healthy diet, reduce alcohol and stop smoking can be a slow process but it was a reminder once again to continue to encourage these lifestyle changes.

After this was an interesting talk regarding non pharmacological managment of chronic pain by Jordan E. Lake from the University of Texas. 55 participants who were aged fifty years or older and who were living with HIV. They had chronic pain for more than 3 months (mainly osteoarthritis and/ or peripheral neuropathy) and were randomly assigned to one of three twelve week treatment options. Either 1) Tai Chi (chosen for its ability to be used by even the frailest of patients) and Cognitive Behavioural Therapy and motivational mobile phone texts or 2) a support group or 3) no intervention. 

The conclusion was that substance use was reduced by both the support group and Tai Chi/CBT/SMS intervention and pain relief and physical function improved by the Tai Chi containing intervention. This reinforced the benefit of patients living with HIV having a chronic disease management plan and team care arrangement for easier access to an Exercise Physiologist and Psychologist from their General Practitioner.

 

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.

See: Nonstop Journey: Delivering an Uninterrupted Continuum of HIV Services to Adolescents and Youth