The final information station on this Italian inspired food for thought train was a digestive Espresso of Epidemiology “Understanding our evolving epidemic”. 

First up was HIV and Ageing – Rosan van Zoest (PhD student at the Amsterdam Institute for Global Health and Development) used cohort data from large studies to separate the Myths from Reality. The opener of the talk was a review of all the suggested AANCC’s (age-associated non-communicable comorbidities). The following speech-bubbles were presented for unpacking “HIV causes accelerated ageing”, “Ongoing inflammation is the cause of comorbidities”, “Comorbidities are due to antiretroviral toxicity”, “AANCC’s occur more often in PLHIV” and “HIV causes premature ageing”.  Data from the COBRA, POPPY and AGEHIV studies were used to respond to the statements and one of the key factors strengthening the evidence was the importance of recruitment of appropriate HIV-negative controls and reference was given to the COBRA study that used HIV- and age matched blood bank donors as a comparison.  After reviewing the evidence, Rosen concluded when reviewing evidence one should be careful not compare ‘apples and oranges’, control groups are vital, AANCC’s are more prevalent in PLHIV, comorbidity risk in PLHIV is likely multifactorial and when considering the above speech-bubbles the following should be considered; smoking, drug and alcohol use, CVD risk and DM, weight related conditions such as obesity and anorexia, HCV, systemic and intrathecal immune activation, certain ARVs and nadir CD4.

As Milan is one of the fashion capitals of the world it seemed appropriate at some point that we talk about Modelling… kind of… Supporting the development of evidence based police/management guidelines was presented by Mikaela Smitt from Imperial College London.  This session was focussed on the “black box” of modelling studies and for those that can comprehend this analogy she used a picture of big yellow minion and thought bubble “WHAAA?!?!?!” as the opening slide…a sentiment I am familiar when trying to get my head around modelling.  Needless to say, she unravelled it brilliantly.

What is modelling and what does it do? It predicts the future, compares interventions, uses epidemiological mechanisms, uses fundamental parameters and suggests resource allocation.

What is good model practice? A new acronym was given to use here (and a picture of the popular Harry Potter Hogwarts popular sport) QUEDDACH.   The QUESTION is concise and specific including outcomes, measures, settings and timelines.  The DESIGN includes what key elements and interactions are represented.  The DATA is underpinned by key/strong data sources.  The ASSUMPTIONS should be defined as well as what impact they have on the results. The CHECKS and sensitivity/uncertainty analyses should be done.

And finally what are the potential problems with modelling data? Wrong tool is used for the job, garbage in = garbage out, Complex questions = greater uncertainty

And so for my final blog of Mind stimulating Mozzarella… (Sorry am running out of cheesy puns.. whoops and again!)

“What is happening with new HIV diagnoses in gay men in England and why? Interpreting monitoring (outputs) and surveillance (outcomes) information” presented by Professor Noel Gill from Public Health England.  Noel started by commenting on England as a high-income setting, the open access network of 200 STI clinics held in high regard by at risk community and excellent surveillance and monitoring systems.  He posed the temporal changes from 2010 onwards noting the HIV complacency with increasing survival and better ARV regimens, problematic increasing density of sexual networking driven by the arrival of geospatial hook-up smartphone apps and a marked increase in bacterial STI’s.  Trends in common STI diagnoses were examined as well as reviewing some of the policy developments affecting them such as behavioural interventions, lower thresholds of access to HIV testing (e.g. the Dean St 1hr promise, self-sampling and Self-testing), Increases in HIV testing frequency following recommendations of 3 monthly testing for those having condomless AI with new or casual partners and HIV PrEP (PROUD trial commencing in 2013). 

Noel concluded with the following information on Preventing HIV in MSM.  Combination prevention has seen a 50% increase in MSM clinic attendees from 2011 – 2016, intensified testing of those at risk has seen an average of 2.5 test annually in 2016 and suggested the question clinicians should be asking is “How frequently are you testing, not when did you last test”.  Shortening the time to treatment initiation in PLWHIV and HIV PrEP has all had a significant contribution. Noel closed by highlighting the commencement of the IMPACT study a pragmatic health technology assessment of PrEP and its implementation that aims to answer the key questions under real world conditions and at sufficient scale.  The results will inform service commissioners on how to support clinical and cost-effective PrEP access in the future.

Thank you to ASHM for your generous scholarship funding for myself and the other Australian sexual health clinicians who benefited from this – we had a blast!  Ciao x

Day 3 at #EACS2017 and my neurone nourishment started with an Antipasto of "Abstract Writing" by Caroline Sabin (Professor of Medical Statistics and Epidemiology at University College London (UCL)). This was an early morning session and the smaller audience lent itself well to an interactive tutorial style where we were asked to critique a ‘poorly written abstract’.  Here are the bite-sized “do’s and don’ts”.

TITLE – Should be short and snappy. DO NOT inaccurately represent the project.  Questions are often great to pose in a title.

INTRO – V. brief!  One sentence to describe the problem and one to describe the research. Hook the reader here by this point the reader should know what you are going to do.

METHOD – Population, location & dates. Identify assessments and methods, endpoints and outcomes.  Describe the stats method (no need to mention the stats model used), DO mention confounders. DO NOT put results here and no need to mention detail such as assay types etc.

RESULTS – DO mention brief demographics of sample, this section should be numbers rich, confidence intervals and comparative statistics.  DO NOT discuss interpretations here. 

CONCLUSIONS – DO NOT repeat results (keep it brief).  DO aim for one or two statements – How will this help?  What is the future? Any major limitations?

Having reviewed many of the abstracts for EACS Caroline’s feeling is that the abstracts tell the reviewer as much about you as it does about your research.  With this in mind her final tips included ensuring correct English language and grammar, is this the right conference for you?, no need for references, use ‘dashes’ effectively they will help your word count, be careful with bold and italics it does not always translate, a little tip …if you must use a table JPEG images often only use one character, avoid jargon.  Finally she commented that abstracts that did not get accepted are largely due to lack of clarity on the project, inappropriate for the conference, poor study design, no sample size mentioned, no bias acknowledged, no clinical value. 

Next up for something to chew on was the first plenary Eradication of Hepatitis C in HIV coinfection presented by Andri Rauch (Associate professor of infectious diseases, University Hospital Bern, Switzerland).  Andri reminded us of the WHO goals of Hepatitis C management.  He discussed the higher the HCV prevalence, the more treatment is needed to achieve elimination.  Scaling up harm reduction reduces the required treatment rates.  He demonstrated a colourful “spaghetti junction” of graphical information showing clusters of behaviours and phylogenetic analysis of international transmission networks to show areas where trends of information can be used to improve counselling and behavioural interventions and where targets for disruption of transmission needs to occur to aim for elimination.  Focusing on Europe he showed data which demonstrated the hurdles to HCV elimination in Europe which are largely around access to therapy, affordability and reimbursement restrictions.  The proportion of re-infections increases with treatment upscale but overall incidence and prevalence decrease if risk behaviour stabilises.  Fear of re-infections is NOT an argument against treatment upscale. In conclusion he stated the central elements of HCV elimination include 1) Optimized screening and diagnosis strategies, 2) Optimized prevention and risk counselling, 3) Increased treatment uptake and access to IFN-free DAA for all at affordable prices, 4) Coordinated national and international HCV strategies and leadership. 

Next up for me today was the Epidemiological challenges of HIV surveillance presented by Anastasia Pharris.European Centre for Disease Prevention and Control (ECDC) in Stockholm, Sweden  Anastasia showed data highlighting the contrast in reported routes of HIV transmission by European sub-regions in 2015 across the West, Centre and East.  Heterosexual transmission accounting for a significant portion across all areas, injecting drug use significantly more in the East and MSM transmission more in the west and centre.  She demonstrated that sex between men is significantly underreported and stigma and discrimination is still a huge barrier. Anastasia commented that Europe is lagging behind in its response to the HIV epidemic and it is not on track to reach the 2020 targets.  She highlighted there are some issues urgently still needing to be tackled, one in particular is the development of policy to include undocumented migrants which account for a proportion of the late presentations and also community viral load which has public health implication.  Finally she talked about more wide scale role out of some successful models such as community based testing, home sampling, PrEP scale up, harm reduction efforts such as needle syringe programmes and opiate substitution programmes and reduction of stigma.

Following on from the breakfast buffet of the bright future for ART and European epidemiology I moved on to the Industry sponsored degustation menu of case studies entitled “Seeing the whole picture” presented by Giovanni Di Perri, Professor of Infectious Diseases at the University of Turin, Italy  & Jürgen Rockstroh, Professor of Medicine and Head of the HIV Outpatient Clinic at the University of Bonn in Germany and a panel of experts. 

Giovanni Di Perri opened the session discussing the prevention of harm in patients with HIV and detailed the common comorbidities associated with HIV and the impact of long term ART such as neurological impairments, cancer, CVD, Bone disease, liver and kidney disease. He highlights the need to carefully manage our patients as a whole, going beyond undetectable, to improve their overall health by considering comorbidities (prevent and treat), counselling our patients on lifestyle risk factors and careful selection of ARTs that balance HIV efficacy, durability and toxicity.  3 case studies were then presented by panel members focusing on differing disease burdens such as bone density, renal function, and prevention in the healthy client with lifestyle factors such as smoking.  Audience participation was required for responses on care priorities, comorbidity treatment options, ART switches and perhaps the one with the most diverse spread of results was in answer to the question when to start ART treatment in the case of a 23yr old MSM diagnosed with HIV that day.  40.4% of the audience said ‘immediately (today)’, 43.8% said ‘once all baseline data were available’, 1.1% answered ‘CD4<500’, 1.7% said ‘Wait, this patient is too young to start lifelong therapy’, and 12.9% said ‘Wait – I need to assess whether this patient will be adherent’.  In this panel discussion reference was made to the San Francisco experience of same-day observed ART initiation versus standard of care and its benefits to viral suppression.  Overall feeling from the panel was a slightly more cautious approach to treatment initiation where one awaits resistance profiling and other baseline assessments before commencing ART to allow for adequate characterisation of any co-morbidities and also time to spend with the client getting to understand their wishes, likely adherence and willingness to start therapy.

And so concludes the second day of yet more mouthwatering (or rather thought provoking) messages and i look forward once again to more palate pleasers tomorrow! 

So having digested all the scrumptious brain teasing morsels at yesterday’s info picnic what was on the menu for Day 2 at #EACS2017?

To begin the day Dr Roy Gulick, Professor of Medicine and Chief of the Division of Infectious Diseases at Weill Medical College of Cornell University (also see Mark Ryan’s post) presented the Future of HIV Therapy.  He began by summarising approved ART first line regimens in 2017 and the world-wide opinion to start at all CD4 counts whenever the patient is ready.  He discussed the developments of ART properties in terms of

1)           Antiretroviral activity - mentioning the future of two new classes of drugs HIV Maturation Inhibitors and HIV Capsid Inhibitors,

2)           Safety and tolerability- giving TDF -> TAF switch as an example of similar viralogical efficacy but improvements in renal and bone markers. 

3)           Convenience- recapping the history of ART with many daily pills to the current single tablet regimes and then the possibilities in the future of new co-formulations with longer half-lives lending themselves of less frequent dosing, and long acting methods in the form of injectables and subdermal implants.

4)           Access and Cost – Highlighting the numbers of people living with HIV globally and improvements in those accessing treatment as the cost of ARV’s decreases.

5)           Life expectancy as those with HIV live longer and healthier lives and in closing stated “possibly longer than the general population … apparently getting healthier is good for you”

The welcome to the conference was at 2pm…and I had already eaten so much “information” gelato I was decidedly full…however as with all good food (for thought).. there is always room for more…so I decided to sample the “Round Table: Modles of HIV testing and delivery of PrEP”

This session was opened by Prof Jean-Michel Molina (Professor of Infectious Diseases at the University of Paris Diderot ) who highlighted some of the issues limiting or preventing the implementation of PrEP in Europe.  He discussed the cost benefit of people on PrEP versus the lifetime cost of treating those living with HIV and the distinct need to highlight PrEP's feasibility. He discussed the need for close partnerships with the community and political support to facilitate PrEP implementation.

Dr Emma Devitt from Dean St Clinic (also see Emma Clements post) highlighted their exemplary model of testing using cutting edge technologies to facilitate patient’s access, testing availability, results turn around and treatment options.  Amongst routine STI services, Dean St service provision includes on site laboratories, HIV and Hepatitis specialist clinics, HIV oncology clinic, Urology and dermatology services, Dietetics, Contraceptive/LARC services, Anoscopy, ED/Psychology/Psychosexual and a Pharmacy service. Most impressively to facilitate their ‘self-testing’ model they have guided self-sampling videos embedded in the mirrors in their bathrooms to guide clients through the process self-collected swabs.   Of course there was mention of the GeneXpert technology which provides extremely quick results turn around but what struck me here was the added option of a web link to the next available treatment appointment should your result be positive - its the total package of care!  Statistical modelling showed that since the introduction of the Express model at Dean St, STI’s are treated 8 days faster than previously and for every 2 people diagnosed with a bacterial STI’s one partner was spared exposure suggesting public health implications and cost savings.  This rapid STI diagnosis and treatment is thought to be one of the causative agents in the recent dramatic reduction in HIV diagnosis seen at Dean St.

Gus Cairns editor of AIDMAP and co-ordinator of PrEP in Europe talked through his personal experiences of HIV diagnosis in 1985 and why he is such an advocate for PrEP in the modern era.  He talked about 20 years of fear inducing messages when condoms were advertised as the only responsible way to have sex. PrEP had brought with it a reduction in the crippling anxiety that many MSM experienced during sex, in PrEP the protective behaviour is separate in time from the risky action itself and described it as ‘enhancing’ sex by reducing the fear. He went on to highlight that PrEP is not enough and in a powerful slide simply put the U=U message (undetectable=untransmissible) reminding me that we need to be confident and unanimous in this message.

Finally and to finish the session was a round table of questions in summary.  These addressed the following questions… How do we approach and include the young? How can we promote PrEP to wider audiences? Is there a future for over the counter PrEP?  Much like describing all the culinary experiences of Gelato tasting in Milan it is impossible to capture the sheer depth and flavour of the responses but needless to say I will find room for more taste sensations tomorrow!

The next session I attended was an industry sponsored session on Maturing Patients, Maturing therapy: Multidisciplinary management in HIV.  The session on management of Cancer in HIV by Christine Katlama (Professor of Infectious Diseases and Head of the HIV Clinical Research Unit
Department of Infectious Diseases France) & Jean-Philippe Spano (Professor in Medical Oncology, in the Department of Medical Oncology of Pr. David Khayat at the Pitié-Salpétrière Hospital in Paris, France) highlighted the increasing medical issue of people living with HIV and cancer diagnoses.  Amongst some interesting case studies, the main points discussed were that viral-induced cancers are more prevalent in HIV positive patients compared with HIV negative patients, the impact of smoking is excessive and needs addressing and multidisciplinary team approaches are extremely important to maximise the therapeutic management of HIV patients with cancers.

They demonstrated a great example of this collaboration in the form of a 6 weekly web-conference that they have set up in Paris between Oncologists, HIV specialists, pharmacists and immunologists where they discuss cases and ensure any possible treatment interactions between ART and chemotherapy are evaluated by experts as well as consideration of the possible benefits of new immune therapies. Whilst perhaps not the direct purpose of the session I found the take home message for me was thinking about the importance of cancer screening and prevention in the comorbidity assessments of stable HIV positive clients that nurses are increasingly involved with.  Smoking cessation should be continually encouraged and revisited at every possible occasion in a supportive way as unsurprisingly tobacco smoking is attributable to many of the cancers diagnosed.

Day 1 @ #EACS2017 did not disappoint!  Much like colourful displays of gelato in Milan’s exquisite restaurants the conference proved to be a veritable feast of tasty information and similar to the difficulty in picking your ice cream flavour so was the conundrum of choosing what session to attend!

To begin the day I started at the WAVE (Women Against Viruses in Europe) Workshop.  I listened to a very empowering speech given by Justyna Kopeć a Polish lady diagnosed with HIV 20 years ago who’s talk was entitled “The longest relationship I ever had”.  She highlighted at least 3 occasions when her diagnosis was missed between 1993 and 1997 which included participating in an anonymous HIV testing at university in which she did not collect her result, vising the gynaecologist with several recurrent vaginal infections and a GP visit for continued weight loss without dieting.  She talked about her journey of hope as new drugs came on the market at the time of her diagnoses, fear of dying, fear of treatment, fear of a daily routine, and trust in her doctors, trust in her family and friends and trust in science and in patient centred care.  She also talked about the changes over time for young women newly diagnosed in today's era in terms of pregnancy and living long enough to watch those children grow.  This session was a great reminder that HIV can affect anyone.  As a nurse I often see clients for HPV wart treatments and other symptoms such as vaginal candida and it reminded me of the importance of thinking of underlying reasons for persisting infections, accurate history taking (as people are transient between services and indeed countries) and not to overlook HIV as a possibility for someone who is not in the forefront of my mind as “high risk”.  Justyna closed with the statement “HIV testing should be a standard procedure among ALL sexually active people”.

Please also see the post from Emma Clements