Mycoplasma Genitalium: Should we look and how can we treat it?

Dr. Tim Read

Mycoplasma Genitalium (MG) is the bug that has all of a sudden made day-to-day testing and treatment in a sexual health service complicated.  No longer can we just test the heterosexuals for chlamydia and everyone else for everything else - MG has raised questions and have had sexual health clinicians almost at logger-heads with what to do about it - who to test, asymptomatic or only symptomatic; what to do if found - straight treatment or reduce the bacterial load first and then treat specifically?

Dr Read showed information from Melbourne Sexual Health regarding the prevalence of infection in both asymptomatic and symptomatic men who have sex with men.  He concluded that if we look we will find!  But is is not clear how a MG in an asymptomatic man might affect that man or his partners. 

It is known that MG causes the same spectrum of infection as Chlamydia and it is known that untreated CT is thought to be problematic in both men and women due to the inflammation it causes - leading to possible scaring, infertility and pelvic infection etc.  But not enough is known about the long term sequelae of MG.

Treatment is complex and MSHS is using long course treatment (doxy/azithro or doxy/moxi) -   However they have also utilised 'resistance-guided' therapy using a PCR  test that not only detects MG but informs the clinician if that particular sample has macrolide resistance. (2/3 of samples in this research were macrolide resistance).  Using this technique they had a 90% cure rate using doxy to lower the bacterial load.

The recommendation he gives for MG are as follows -

Treat NGU with doxy pending MG test

consider reducing the azithro when coinfection with MG likely

base therapy on known of likely macrolide resistance

do not screen asymptomatic people for MG

need more data on prevelence in heterosexuals.

Dyspareunia - understanding sexual pain

Lynda Carlyle

This is an important component of the sexual health work done at the Townsville Sexual Health Unit - unlike other sexual health services there is not many others that have the capacity, capability or willingness to talk about sexual function, pain and good sex with their clients.  Townsville works within a sexual 'health' model - a wellness model - and therefore having an enjoyable sex life is just as important as ensuring that the client is disease free.

Dyspareunia is a major issue with many women (and men) and the 'pyscho-sexual' issues can be overwhelming for some people who suffer pain with sex.  Learning how to help people with sex pain isvital for sexual health practitioners - there are no sex therapists  in the regional and remote areas (generally) - there are none that I know of in Townsville.  It was therefore really important for sexual health clinicians to  learn from the 4 speakers and the chair of this session on Wednesday (8th Nov).

one area that struck a cord with me was the model of bad sex  and how it can be reversed.  Many clients have sex out of 'duty' which leads to anxiety, tension, lack of arousal and painful sex.  As a clinician giving the client 'permission' to say no to sex for a time frame where some pain relief strategies can be in place or developed with the client and their partner was really important.  Many clients may not

Lymphogranuloma Venereum in the era of PrEP: are we heading for another epidemic?

Professor David Templeton. Normal 0 false false false MicrosoftInternetExplorer4

Professor Templeton presented a paper on the transmission dynamics of rectal LGV.  He gave information regarding the prevalence of infection being significantly more prevalent in gay and bisexual men (GBM) and even more significantly higher in HIV positive men.  He posed the question ‘Is it all behaviour or does immunodeficiency play a role?’

The research he had looked at suggested a differing theory of CT transmission (including the LGV serovars) this being the role of ano-oral transmission from gut reservoirs of infection passed through faecal-oral contamination.  In comparison to the thinking that it might be past via rimming and fisting. CT can be transmitted from the urethra of men into the throat of their partners, it then is carried through the gut (the gut with it’s down-regulation of inflammatory responses allows CT to survive), it then infects the rectal mucosa and sets up a persisting infection (that then might lead to symptomatic or asymptomatic carriage of LGV or CT.)

This has been suggested by several authors that I found in the reference list of the paper Professor Templeton was quoting –  The Enigma of Lymphogranuloma Venereum Spread in Men Who Have Sex With Men: Does Ano-Oral Transmission Play  a Role? de Vries, Sexually Transmitted Diseases 43, 7, 2016.  Some of the work is based on animal models – where animal CT and ‘LGV – like’ infections occur and persist in the GIT and are not cleared with macrolide treatments.  

There are some studies by one author who looked at  infection in babies at risk of CT infection at birth and how long it took for the infection to get to the anus of the baby and the vagina of the baby girls – postulating that the infection had to travel through the gut and then through feacal contamination enter the vagina. (for further information read  Hidden in Plain Sight: Chlamydial Gastrointestinal Infection and Its Relevance to Persistence in Human Genital Infection Rank & Yeruva, Infection and Immunity 2014 ;82 :4,  1362–1371.

In practice this has implications for testing and treatment as rectal CT and LGV are vastly different to uro-genital infection.  Therefore non-sexual health clinicians must ask about sexual practices (or just test every orifice in both men and women), GBM with proctitis or procto-colitis who get sent to Gastro-enterologist must have an anal swab first (symptomatic LGV can present as Crohns Disease for example and be missed) and any GBM with ano-rectal CT infection should have their sample sent for LGV serovar testing.  The research is suggesting that heterosexual transmission of LGV is very unusual however continuing vigilance and surveillance is needed to detect shifts in infection dynamics within our community.

Rates of Transmitted Drug Resistant Mutations in Newly Diagnoses HIV in NSW 2004-2016

Angie Pinto

This was interesting as the results showed more transmitted HIV drug resistant mutations  found in the rural and regional areas of NSW, in younger people, with <10% mutations found.  Although Ms Pinto suggested this could not be generalised to populations outside of the NSW research areas I think it highlighted the need for vigilance in remote, rural and regional Australia.

Fortunately living in a rich nation we are able to request HIV genotyping tests with each newly diagnosed HIV case  and this is usual practice. It is also very fortunate that there were no resistance mutations found in Tenofovir and only a tiny number against Emtricitabine  -  which of course are the 2 drugs used in PrEP.

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2.  Tuesday 7^th

Labiaplasty: factors leading to increased requests among women from a survey of GP experience.

Magdalena Simonis

This talk was really very sad in many respects.  In my own practice I have experience of young women (as young as 15yrs) wanting to have their labia modified, often without ever seeing other labia to know how normal they are.  With the adolescent body changing so dramatically at 15 it isn’t hard to understand the horror some young women must feel when they notice the changes to their genitals-  looks, skin, hair, discharge etc. Luckily these concerns can be addressed and reduce the health anxieties of the client with correct information.  Unfortunately, many young women in our society are not given any information about this – and certainly in my practice many women have no idea that they need a vaginal discharge every day for example.

Some of the concerns raised included the lack of knowledge of how these surgeries when done are going to affect the women as she ages – with atrophying of the labia during menopause.  There is now knowledge however on how it may cause considerable distress and discomfort if the surgery is not performed correctly or if there is some complication – bleeding, infection and pain etc. 

Some of the long-term effects may be hypersensitivity – especially if the clitoral hood is shortened to expose the clitoral bud. When even the wearing of clothes may be painful. There may be decreased sexual sensitivity if the edges of the labia minora are removed (there is a technique where the body of the labia is ‘wedge-resected” to avoid the more sensitive edges of the labia.) 

This procedure is the 4^th most common cosmetic surgery after the nose, liposuction and breast augmentation in Australia, the surgeon does not have to be a registered cosmetic surgeon and the client over 18 years does not have to have counseling or a cooling off period.  Women under the age of 18 have to have a 3-week cooling off period just in case they change their mind.

I have heard some arguments that this surgery is no different than having other parts of the body being modified  - the women's reasons for having their labia reduced is because of the physical look (aesthetics) or a functional concern but this talk that gave examples of the research around the psycosexual distress, relationship concerns and sexual assault that women have experienced when counselled. 

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ASHM CONFERENCE 2017

Undetectable Viral Load Prevents HIV Transmission in Male Serodiscordant Couples in Australia, Thailand and Brazil.

Benjamin Bavington

Monday 6^th

One of the first presentations in the 2017 ASHM conference was the talk that was initially given to the Paris IAS conference in July this year on the final outcomes of the Opposites Attract Study.  This research was unique as its focus was on HIV transmission in HIV discordant male gay couples.  This study showed no linked transmissions between discordant couples where the positive partner had an undetectable viral load.  The researchers took phylogenic ‘finger-prints’ of the positive partners virus at the beginning of the study so if the other person became positive they could determine if it was the same virus.  To be included on the research the gay couple had to attend at least twice per year, the positive person had a viral load, STI check and questionnaire, while the negative partner had an HIV test and STI check plus the questionnaire. The following is just a glimpse of the statistics from the research

·         343 couple were followed

·         2 international sites (Thailand and Brazil), 13 Australian sites for recruitment

·         ~40% in the first year of the relationship – historically there is a larger potential for transmission in this first year compared with longer term relationships

·         75% of the pos people were on ART for the entire study, 25% commenced during the course of the study

·         Of all the positive participants on ART -  75% were fully suppressed, this was due to numbers from the Thai cohort skewing the figures – the Australian cohort had much greater numbers of positive participants being fully suppressed.

·         At the beginning of the study only 7% of negative men were on prep – this grew to 30 % by the end of the research

·         35% of the participants had a STI during the research period

·         In the Australian cohort ~68% reported condomless anal intercourse (CAI) at the beginning of the study and 88.9% by the end. 

·         There were 3 partners who became positive through the project – none of these infections were linked to the positive partner.  All 3 people reported CAI outside of the regular relationship

The conclusion was that with the partner having an undetectable VL there were no linked transmissions.  It is not clear how the role of STI plays in this cohort with regard to transmission of HIV.