ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

2016 update on the National PEP guidelines.

Attitude by staff is a deterrent to people seeking PEP - this is often reported by people who have seroconverted and attended for PEP in the past (a message to staff in the emergency department).

Undetectable viral load? You need to be sure that the source is reliable (the devil is in the detail).

What drugs to use - Combivir is gone, we should all be using TDF/FTC or TDF/3TC.

3-drug PEP (DTG, RAL, RPV).

Prompts for NSW HIV Strategy - spike in notifications in 2012, increasing condomless sex, delays from infection to diagnosis, strong evidence for TasP, UN declaration to reduce HIV by 50%.

The second strategy had new evidence - early ART irrespective of CD4 count, 90% of people diagnosed on treatment within 6 weeks of diagnosis, evidence of efficacy of PrEP, 95% of those diagnosed on treatment.

Introduction of 6 monthly follow-up surveillance.

Enhanced data has been collected since 2014 on patients with a HIV diagnosis from 2013 onwards, and is ongoing.

Change from making HIV notifiable by laboratory to notifiable by clinician also, giving them the authority to provide information about their patients.

94% return rate on the questionnaires.

60% on ART in 2013, 84% on ART in 2016.

Of those diagnosed in 2015, 90% are retained in care 6 months post diagnosis, 87% commenced on ART within 6 months of diagnosis, and 75% reached viral suppression.

Improved health outcomes, and at community level reduced transmission risk.

Determine predictors of early treatment and monitor the rate of adoption of early treatment.

Data source is most of the 83 clinics in Australia, analysis by the Kirby Institute.

Include diagnoses from 2004 to 2015.

Excluded inconsistent or incomplete records.

863 patients in the analysis.

Median CD4 count was 500.

Viral load higher in the earlier time period of the study.

Predictors of early treatment were low CD4 count, high viral load, and later year of the study.

Sociodemographic characteristics were not associated with early treatment.

PrEP has been used in NSW by high risk individuals since 2011, with a significant increase in 2016.

It has been limited by cost and availability.

Who should have access to PrEP, given limited resources? - The high risk patient approach.

Demonstration study - PRELUDE 2014-2016 government purchased generics

Estimated 4% (12 of 300) of PRELUDE study patients would have seroconverted, but none did.

Individuals are usually highly motivated.

Blood tests in these studies suggest very high levels of adherence.

The implementation trial EPIC-NSW.

Estimated that there must be 3700 high-risk individuals in NSW

It was estimated that the highest risk 11% of the gay community would comprise 3700 people,  but so far we have recruited 4000.

EPIC aimed to target this group and enroll them on a PrEP study.

EPIC-NSW estimates 150 participants should have seroconverted by the end of the study, it is early yet, but so far none have.

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

 

 

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