In the Treatment as Prevention session Thursday 17 Nov John McAllister, HIV CNC at ST Vincent Hospital Sydney, presented a 5 min rapid fire overview of his poster "Post-Exposure Prophylaxis for HIV: What else to consider.

The 2016 PEP Guidelines were updated by an expert reference group taking into account new information on the following:

• TasP for condomless anal sex
• PEP/PrEP interface
• Choice of ARVs for PEP
• 7 vs 28 days at initial presentation
• Some documented negative experiences of those presenting for PEP
• Use of PEP in children

Some of the main changes to the PEP Guidelines are:

• PEP is no longer routinely recommended for any non-occupational exposure where the source is on ARV with a non-detectable viral load (ND VL).The previous PEP Guidelines (2013) recommended PEP for MSM anal intercourse where source VL ND.  The change to recommending no PEP for these exposures is based on data showing no HIV transmissions in heterosexual or homosexual couples where source has ND VL. 
• Individuals presenting to sexual health clinics or GP s100 prescribers may be given the entire 28 day PEP prescription rather than 7 day starter packs. Those presenting to Emergency Departments may only be provided with starter packs.
• Someone currently taking PrEP, but who has not been sufficiently adherent, and has a high risk exposure within the previous 72 hours should be considered for 3 drug PEP
• Choice of drugs for 2 drug PEP are tenofovir/lamivudine or tenofovir/emtricitabine (Truvada). AZT based regimens are no longer recommended. 
• Preferred agents for the 3rd drug are dolutegravir or raltegravir or rilpivirine. The main considerations when choosing are dosing, SE and DDIs
• Individuals re-presenting with an additional exposure while currently on PEP should have the course extended to 28 days post the most recent risk event
• A statement that highlights the importance of a non-judgemental approach by clinicians to individuals presenting for PEP. Judgemental attitudes have been documented to have prevented people presenting for PEP on subsequent occasions of risk.
• Section on prescription of PEP for minors
• The 2016 PEP Guidelines are available at www.pep.guidelines.org.au

 

 

Well I didn't think I'd be blogging on the penile microbiome, but Cindy Liu, Assistant Research Prof from George Washington Milken Institute School of Public Health gave such a fascinating talk on the role of the penile microbiome in relation to circumcision on acquisition of HIV that I wanted to at least highlight this research. It is of interest to my role as CNC of Victorian NPEP Service given that circumcision is taken into account when assessing HIV risk for men having insertive intercourse.. My understanding of why circumcision is protective has just increased. 

Firstly, microbiome throughout the body is being increasingly recognised in playing a role in certain diseases.

Circumcision is known to be protective against HIV acquisition for the following reasons:

1. Decrease in at-risk surface area i.e. epithelial lining of foreskin

2. Increase of keratinisation 

3. Change in the sub-preputial micro-environment 

4. Change in penile microbiome

The study involved taking a swab from the coronal sulcus at baseline and 12 months in 2 groups of men - those who were circumcised and those who were uncircumcised.

There was an increase in both the type and density of anaerobic bacteria in uncircumcised men, and a small increase in skin associated "good" bacteria. The anaerobic bacteria found were pro-inflammatory, therefore attracting cytokines to the area, activating HIV target cells, such as Langerhans cells and increasing risk of HIV acquisition.

That is it in a nutshell and I am looking forward to Cindy's next talk this afternoon on BV, a condition we know is characterised by proliferation of anaerobes, and HIV acquisition

 

Daniel Richardson talked about the increase in sexual transmission of HCV and who to test and when.

A very brief overview of when to screen:

* For heterosexual couples: linked HCV transmissions rare and screening for HCV not recommended

* For HIV positive MSM: HCV transmission associated with increased sexual partners, syphilis, condomless anal intercourse, group sex, chem sex and practices such as fisting.  Screening is recommended annually

* For HIV neg MSM the risk factors for sexual acquisition of HCV are similar to HIV positive MSM 

Screening is not recommended for HIV neg MSM without the above risk factors 

Annual screening is recommended for HIV neg MSM with the above risk factors, and for those who are using PrEP