Day 2 of the conference and there have been more thought provoking sessions. The afternoon "Drug and Alcohol Session" raised a number of issues for clinical practice and for future research and confirmed what I have been noticing in patient presentations over time, with more individuals reporting regular use of methamphetamine.

Mo Hammoud, Project Manager of the Flux study (Kirby Institute) and his talk on "Highs and Lows of Methamphetamine Use among Gay and Bisexual Men" referred initially to data from the HIM study with odds ratios for risk of HIV seroconversion being: 1.8 with methamphetamine use, 4.1 with erectile dysfunction medication (EDM) use, and 8.1 with both methamphetamine and EDM use.

In the Flux study, examining the relationship between EDM and methamphetamine use, Mo indicated that many men are using EDM for pleasure, that this may not be associated with erectile dysfunction, that EDMs were more commonly being obtained from outside the health system (online), and that men who use EDM are more likely to engage in condomless sex, group sex, and to use methamphetamine. The implication of this is that it highlights key indicators for HIV risk behaviours and transmission.  

In their research looking at methamphetamine use they found that over 80% smoked while around 30% injected, 30% used monthly, 13% weekly and 4% every day. When asked about reasons for methamphetamine use the top response was "for fun" (around 70%). The reported "highs" of methamphetamine use were ranked 1) had better sex (60%), 2) I felt happy, 3) had some great parties, 4) gained more confidence, 5) met new friends, and 6) brought me closer to people (40%). Conversely, the reported "lows" of methamphetamine use included a number of responses but with the top response (around 50%) being "had unsafe sex". Overall the men reported more highs than lows in their reasons for methamphetamine use. The research also found that condomless sex was significantly more likely with recent methamphetamine use.

Studies such as Flux are highlighting important isues to consider in targeting HIV transmission in certain groups but also possible aspects to focus on in working with individuals when trying to address methamphetamine use, providing better understanding of the likely reasons for use as well as the downsides of use. 

In my job as a clinical neuropsychologist assessing HIV positive individuals for possible cognitive impairment I am increasingly seeing people present with a mixture of contributing factors for cognitive impairment and with crystal meth use becoming more of an issue over the last few years. The session today focussed on use of methamphetamine and risk behaviours and provides important information to consider. Over time it would be great to see more research on the longer term impact of methamphetamine use by HIV positive individuals and also more funding and services to enable ready access to treatment for those seeking to reduce or cease methamphetamine use.  

An interesting first day with varied sessions. It was great to hear about a number of very positive treatment approaches using the newer drug options for HCV, the direct acting antivirals. The afternoon session "Ending HCV in Populations" included Professor Greg Dore on HCV treatment as prevention in prisons and Professor Margaret Hellard on treatment and prevention to eliminate HCV in people who inject drugs.

Prof Dore indicated that of the 30,775 Australian prison population there is 30% HCV prevalence but with HCV antibody prevalence in prisoners varying across the states e.g. 52% in QLD, 26% in NSW, 25% in VIC. In prisons there is 60% prevalence of injecting drug use, with 10-15% annual transmission of HCV yet currently no preventative vaccines available, no needle and syringe programs and limited harm reduction methods available. With the new treatment options there is a much greater scope for targeting treatment of larger numbers of prisoners, with the SToP-C study addressing this. 

Margaret Hellard highlighted a shift in focus of who to target in treatment of HCV and expectations re the impact it produces. With 8,000 to 10,000 new HCV infections annually and PWID key drivers of HCV transmission, she stressed that you don't need to treat everybody with HCV to get a reduction in prevalence. If 40 out of 1,000 PWID are treated it can have a significant impact - it would reduce HCV prevalence by 50% over 15 years.  

With the new and future HCV treatment regimes having fewer side effects, high effectiveness, allowing improved dosing schedules and shorter treatment duration it will allow different models of treatment. From work by the Burnet Institute it has been found that social networks of PWID substantially impact transmission rates. A "treat your friends" strategy - treating certain individuals of the network they inject with - could lead to reductions in risk of HCV reinfection post-treatment, and reduce HCV transmission through the network. The TAP study will assess community based treatment of PWID and their injecting networks, looking at rates of HCV primary infection and reinfection.

The take home message from these talks is that with direct acting antivirals for HCV there are now new opportunities to scale up treatments and look at different approaches to treating populations in need.