Slightly belated report back from Friday morning's session.

President of AFAO, Dr Bridget Haire opened this session - in the absence of Dr John-Paul Sanggaran, the former Medical Officer, Christmas Island, Queensland. Bridget read extracts from a moving letter Dr John penned to highlight to governing bodies the multiple inadequacies in health management of HIV testing and treatment on Christmas island.

In it he pointed out that often an HIV test result takes at least 1-2 weeks due to logistical factors, by which time the patient has usually been "processed" and moved on to another island and so they will not receive their result in time.  If the HIV result is positive then there are further problems once the patient has been tracked down, as they have been transferred to places such as Nauru where treatment access and roll-out is sub-optimal.  He then described how HIV positive refugees on the island had often been placed in the "White Building" - usually reserved for people with behavioural difficulties.  His experiences really highlighted the challenges faced by clinicians and patients alike, in difficult health care settings, in stark contrast to my own, well resourced Sexual Health Clinic in Sydney.

Then in the second session Dr Kathy Petoumenos presented findings from the ATRAS Study Group: The Australian HIV Observational Database Temporary Residence Access Study, of which several patients from my clinic have been gladly enrolled.

The NAPWHA group engaged various pharma companies to provide free ART to 180 medicare-ineligible patients for up to 4 years.

This study aimed to determine reasons for Medicare ineligibility, time to become eligible for HIV treatment on Medicare, and assess their long-term clinical outcomes once on ARTs. Enrolment was from 2011 - 2012. Results from the 24 month findings were presented.

Interesting results from baseline showed that 73% were male, most common visa status was Student Visa (34%) and 63% of the cohort had experienced prior ARTs (either as self-funded, trial participant, origin country or compassionate access).

Encouragingly over the period of the study, the mean CD4 count increased from a baseline of 376 to 534 at 24 months. Even more pleasing was that the percentage of patients with an undetectable viral load increased from 47% at the start of the study to a fantastic 94% at 24 months, with 100% of females achieving undetectable viral load.

So far 74% of participants have dropped out as they became Medicare Eligible, 17% have gone overseas and 9% were lost to follow up. Students were least likely to have stopped requiring ATRAS medications.

In the 2nd part of the presentation the group attempted to estimate cost benefit of expanding ARTS to all medicare-ineligible patients. The survey findings estimates there are approximately 450 medicare-ineligble HIV clients in Australia.  After 2 years patients with a detectable viral load reduced from 53% to 6%.  i.e. a 93% risk reduction in onward transmission of the infection.  Thus 81 new infections would be averted/ 5 years. 

Mathematical modelling using these figures shows that expanding ARTS access and treating all the temporary resident HIV+ population was determined to be at least cost-neutral - i.e. it saves as much as it costs.   Of course, the public health benefit and the benefits to the HIV-supressed individuals alike is so much more than that.

Aaron Cogle (Exective Director for NAPWHA) pointed out that medicare-ineligible people are not recognised as a priority population nationally, this and other federal and state barriers to ART access need to be tackled imminently.   If universal test-and-treat policy is to be realised then this population needs to be included.

Atras Ceases Nov 2015.

Sadly I was unable to attend the last presentations in this session as I had to catch my flight.

What a great conference, see you all in Adelaide (and Rio) and thanks to all or any who managed to read this far into my blog!!

 

HIV and Women's Health was the topic of Wednesday morning's stream. Much interesting and varied work was presented. I will attempt to summarise below.

Damian Jeremia presented his work entitled Prevalence and Factors Associated with Modern Contraceptive use among HIV-positive women aged 15-49 years in Kilimanjaro region, Northern Tanzania.

Women's responses to a questionnaire and interview in Swahili language were aggregated. Results showed that only 54% of these women were using a form of modern contraception. Male condoms were the most common contraceptive method (25.4%). He cited lack of contraception information and lack of combined reproductive health and HIV services being the main barriers in contraception use. 

Dr Lisa Noguchi presented on some complex findings from women participating in the S African-based VOICE trial. The VOICE trial is a Phase 2B trial of women using tenofavir as HIV prevention, and one of the eligibilty criteria required having effective contraception.  Lisa's secondary analysis of the data looked at injectable Progestin contraception and acquisition of HSV2 Infection. Injectable progestins are the most common contraceptives used in S Africa. Whilst some data suggests hormonal contraception may increase HIV-1 risk for women, recent studies have suggested there are differences in this risk between the 2 commonly available progestin injectables - DMPA and NET-EN. Retrospective analysis of the VOICE data showed HIV-1 was higher for users of DMPA vs. NET-EN (aHR 1.41, 95% CI 1.06-1.89) p=0.02.   However, the risk of HSV-2 acquisition  between the 2 types of injectables turned out to be not significantly different.     She noted that the data was extracted from the VOICE study retrospectively, which was originally designed to demonstrate different data and results could therefore be prone to bias.

 

Shaun Barnabas presented longditudinal cohort data on genital symptoms and STIs in just under 300 women aged 16-22 years in different cities of S Africa. The Cape Town cohort was more risky in behaviour with a high prevalence in STIs vs. Johannesburg, specifically a higher prevalence of chlamdyia, gonorrhoea and HSV-2. There were low rates of symptoms reported across the board,with "normal vaginal discharge" being the most common symptom (58%) and "abnormal discharge" 8% at baseline.There was little correlation between symptoms and STIs. This is an issue as S African guidelines are based on syndromic management, thus potential for under treatment is significant. 

His final question was "Is it time for the SA government to move away from syndromic management?"  The resounding answer from the audience response was "Yes!".

 

Alison Norris educated us about the gender differences in HIV testing and knowledge in Rural Malawi, one of the poorest per capita countries in the world. There were encouragingly very high rates of HIV testing in both sexes. Most powerful predictor in whether someone of either sex had ever had an HIV test was knowing the partner had received a test. Ultimately their prediction that there would be significant differences between testing and knowledge between men and women was unfounded.

 

A/Prof Sheona Mitchell talked on uptake of cervical cancer screening among HIV positive women participating in a pilot RCT in Uganda: the ASPIRE project (a collaborative study between Canada and Uganda).  The aim of the ASPIRE project is to inform policy makers about cervical screening programs in resource poor areas.

They studied 500 women in an urban community in Kampala. Usual cervical screening involves visual pelvic speculum exam with acetic acid application.ie invasive. The potential for a less invasive test such as a self-collected swab detecting high-risk HPV strains is a novel, attractive approach for low-resource settings. HIV positive and negative women were randomised to speculum visual exam or self-collected swab. 

Self collection of swabs had a high uptake in both HIV pos and neg women. It was found to highly acceptable, improved access and had high rates of retention going forward to further exam and treatment (compared to visual exam alone).  She was hopeful of future POCT for the HPV swab to further reduce barriers to cervical screening uptake. 

 

Elizabeth Fearon then finished up the session by presenting interesting data on a method to estimate the national prevalence of HIV among female sex workers in Zimbabwe by pooling data from Multiple Sampling Surveys and Programme Consultations.

My take home message from all of the above presentations is that there is much great innovative research going on in some of the most resource-stretched places on Earth.   Many small steps are being made towards improving access to screening, testing, support and treatment for women (both HIV positive and negative) from these difficult to reach populations and places.  But there is still a long way to go.

 

Prof Myron Cohen, the lead investigator of the multinational HPTN052 trial kicked off today's Plenary clinical presentations with Treatment to Prevent HIV: Does timing matter?

Great overview mentioning that risk of transmission is explicitly related to viral load. 

His breaking news: HPTN052 trial has found an overall 93% risk reduction of contracting HIV in ITT analysis of sero-discordant couples. And even better news was that the 8 linked partner infections that occurred whilst their partner was on ARTs occurred either before ART was commenced or when the partner was actually failing ART therapy (i.e. had a detectable viral load).

This means NO infections were observed when the partners' HIV replication was suppressed. 

He then highlighted that a significant proportion (19-52%) of HIV transmissions occur during early/ acute infections, adding much weight to the argument for very early ART treatment.  

His message was applauded and was loud and clear to "Start ART Now!"