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.

Testing and Treatment

Posted by on in Testing and Treatment

This was a sponsored satellite symposium, held at the ASHM/Sexual Health conference. It consisted of a panel discussion which was chaired by Dr Norman Swan.

The question posted was- Can Australia be Hep C free by 2026? The short answer is....possibly.

Back ground

Hep C eradication treatment started this year. 20,000 people have been treated and by the end of this year 45,000. The bulk are patients were keen for treatment. Currently 82% of people with Chronic Hep C in Australia, have been diagnosed. This leaves 22% diagnosed. There is a dis-proportionally higher prevalence in the indigenous and incarcerated populations.

Resistance to treatment

Concerns remain in co-infected patients, that eradication treatment is difficult or may impact their HIV.These concerns linger from previous Hep C eradication treatments. They don't translate to the new treatment.

There are some drug interactions between ART and Hep C eradication treatment, however these can be managed.

Attitude change

An attitude change in government, patients and health care providers is required, to identify the remaining 22% of undiagnosed patients. This is needed, as without a significant reduction in Hep C in the general population, reinfection may occur. Re-treatment will then be required, and should be offered.

Hep C resistance

This has already occurred and needs to be avoided. Ways to prevent resistance is discussing with the patient to determine if they can access and afford the medication, for the entire treatment course. A wavering of the cost of opioid replacement therapy, needle exchange in prisons, nurse practitioner to subscribe treatment and patient education on preventing reinfection, will also contribute to preventing resistance.

Take home message

The uptake of Hep C treatment has been fantastic. Limit the opportunity for resistance by reducing the opportunity for partial treatment. Educating patients on preventing re-infection. Identifying patients who may have Hep C but never tested.

If this treatment to work, then we (and the government) needs to approach this treatment, like the Small Pox Eradication Program.

 

 

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Professor Rebecca Guy from the Kirby Institute delivered a talk on how new technologies are important for STI prevention. Media technologies allow young people to 24-hour access to information on sexual health. Computer assisted survey instrument (CASI) is an efficient way for clinics to collect information and triage clients. It is acceptable to both patients and clinicians. Studies have found women are more likely to report higher numbers of male partners via CASI than during a face to face consult with a clinician.

ACCEPt is a prevalence study, which aims to assess the feasibility, acceptability, efficacy and cost-effectiveness of annual chlamydia testing among 16–29 year olds in the general practice setting. Findings from the study include: 73% of chlamydia cases in the study were asymptomatic patients attending for non-sexual health reasons. This highlights the importance of offering all young people chlamydia treatment at GP visits. 

Point of care testing (POCT) in rural areas has been successful. POCT can significantly reduce the time from diagnosis to treatment in many clients-especially marginalised populations who are often transient.

 Professor Mark Hayter from the University of Hull spoke about integrated sexual health services and highlighted the need for school based sexual health clinics. There is some evidence to show a reduction in births to teenage mothers and a reduction in chlamydia rates among young men in young people who have access to school based sexual health clinics.

More focus is needed on alcohol misuse interventions and services. Alcohol consumption can reduce inhibitions and can lead to unsafe sexual practices. Clinicians should include alcohol and drug history as well as the patients sexual health history and provide brief interventions and referrals to appropriate services as needed.

It was also highlighted that whilst PrEP is very important for HIV prevention we also need to counsel men around safe drug use when they engage in “chemsex” as this can pose further r

 Christopher Fairley postulated that pharyngeal gonorrhoea could be transmitted by saliva-via deep kissing and by using saliva as lubricant; which stirred great interest among the attendees in this morning’s session.  Anti-bacterial mouthwashes may be the way forward in substantially reducing gonorrhoea prevalence. Watch this space!

 Catriona Bradshaw discussed Mycoplasma genitalium (MG) and Chlamydia trachomatis (CT) infections in the rectum. There is no standardised treatment for rectal chlamydia. The Centre for Disease Control guidelines does not distinguish between urogenital and rectal chlamydia.

Doxycycline appears to be the best treatment for rectal chlamydia. A randomised control trial is underway and this will inform treatment guidelines for rectal chlamydia.

MG has been less studied that CT and the data available on rectal MG is limited. MG testing is unavailable in many settings and may take 2 or more weeks to get a result.

There have cases of macrolide resistance, which have meant that this clever bacterium may need dual antibiotic therapy to treat and there is a great need for more antibiotics to be developed.

Key messages

-Doxycycline should be used over azithromycin for rectal chlamydia while awaiting RCT evidence

-Rectal MG is commonly asymptomatic and more common in HIV positive males

-MG is predominantly macrolide resistant

-Better treatment guidelines and treatments are needed

 Jane Tomnay- Patient-delivered partner therapy for STIs: the current state of play in Australia

Patient delivered partner therapy (PDPT) describes the practice in which treatment is prescribed for the sexual partner/s of an index patient diagnosed with a sexually transmissible infection, as well as the index patient. The patient then delivers a prescription, or the treatment, to their partner/s. PDPT aims to target those partners who are unwilling, unlikely or unable to consult a health professional in a timely manner.

Jane presented about the difference between a ‘provider referral’ versus ‘patient referral’ for the treatment of STIs. PDPT can be less resource intensive and was found to be acceptable to many. PDPT is already happening in Australia and the NT has taken the lead with this initiative.

Key messages

-PDPT works

-PDPT for chlamydia using azithromycin is safe

-Pharmacist’s knowledge regarding PDPT was low therefore education is needed

-In trials there has been no difference in partners followed up between medication PDPT and prescription PDPT

 

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Day 2 - I found Christopher Fairley, Melbourne Sexual Health Centre, Alfred Health, VIC, Australia witty and captivating!

He gave a quick talk on Pharyngeal Gonorrhoea questioning WHY is it SO common in MSM - why not Chlamydia or HPV??

Are they kissing more partners? 

As there's no difference in rates of oral sex between MSM and MSW or the rate of transmission if they only kiss or kiss plus have sex.....it doesn't make sense!!

He suggests that gonorrhoea is transmitted in saliva and saliva is used as a lube when rimming and that the penis is irrelavant to transmission of gonorhoea in MSM.

He also spoke about using an antibacterial mouthwash such as Listerine to substantially reduce transmission of gonorrhoea 

Sexual Health Day 2 Mycoplasma Genitalium

Mycoplasma Genitalium has a high prevalence within the community, is difficult to test for as well as being tricky to treat.

Mycoplasma his the cause of significant pathology including intrauterine death, PID, proctitis, cervicitis and urethritis.

Traditional treatment has always been 1g Azithromycin however there is significant emerging macrolide resistance. This leaves only Moxyfloxacin which is hard enough for me to get as a GP and Pristinamycin currently needing to be imported from France...

As reported we clearly need better testing that includes resistance screening as well as new antibiotics to target this insidious infection.

Mycoplasma Genitalium has certainly been a "theme" at this event and will be a a big part of future work. I have to wonder if MG infection may have been responsible for the many cases of "sterile prostatitis" I have treated over the years...

Watch this space.

 

Great session today on rectal Chlamydia today that will definitely change the way I practice.

Rectal Chlamydia can be difficult to treat with increased resistance to Azithromycin (1g stat dose = 86% cure)...

99% cure has been noted with Doxycycline 100mg BD for 7 days.

Question is should this change my practice?

For me the answer is perhaps..

If compliance is an issue it may be best to do 1g Azithromycin and then test for cure. Have Doxycycline in backup for failure.

In severe symptoms and/or the patient is likely to have good compliance I thing I will change to the Doxy regime, also with test for cure...

 

 

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