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.

Recent blog posts

This morning I watched a presentation by Joshua Rosenberger (USA).Examining the role of STI prevention among MSM using mobile applications.

He was discussing a study that was conducted in a American city with a population of about 1 million people. Looking at how many MSM that logged into a particulat Geospactial networking app within a 24 hour period.

And where these men lived in relation to the Sexual health and HIV services that were available in the city. 

In a 24 hour period 5000 men logged into the Application. Most of the men being of white or Hispanic background and living in the inner city and downtown area. There was a population of African-American background that lived further on the outskirts of the city. The peak time for log on being 2000 through till 2300.

Using this information and location of the men that logged in they could see the centres for access (their clinics were all located in the city area). Which was great for the small population of white men that lived in that area. But not so for the rest of the population. Especially there most at risk men of African-American background. 

The clinic hours extended until 1730 at the latest. So how could they use this information for health promotion and to allow for better access to the rest of the population at greatest risk for STI/HIV prevention and education?

 

My Take HOME MESSAGE:

Harnessing the use of mobile application services is a great way to ascertain where the target population are living and using the platforms for advertising "Health Promotion".

In Australia and especially in NSW we have embraced Mobile Social Applications such as GRINDR to deliver Health promotion activites. But can we better utilise the data to look at where we need to direct outreach services to capture the proportion of the population that do not live in "The bubble" of the innner city - where a lot of our Sexual Health and HIV services are located. 

Today I watched Catriona Bradshaw (Monash University, Melbourne) present on M.G.

WOW. Great presentation.

M.G Slow to grow and difficult to culture. 

Looking at resistance patterns around the world its very clear that over prescribing of Azithromycin has lead to macrolide resistance in M.G.

Looking at countries that have prescribed STAT Azithromycin for NGU and now looking at resistance profiles its very evident that we need to change our thinking and prescribing.

Catriona showed the resistance profiles of two countries side by side - Sweden and Norway. One Country having used Azithromycin in NGU treatment and the other having used Doxycyclin. Very different results.

It made me think of the landscape in Australia - and the different drugs being used in current guidelines. Which I might add are always evolving with new evidence.

Russia has a low prevalence of resistance - Its not used Azithromycin.

Countries that have used Azithromycin in NGU have had an increase in resistance from 10% to 40% in 10 years.

Widespread use of Azithromycin for STIs and Syndromes has led to high failure rates for M.G.

Some regions already leading the way - U.K. And Europe changing guidelines to recommend Doxycyclin.

We need to move towards testing that can perform resistance testing so treatment can be individualised.  This will shorten the duration of infection, reduce transmission of resistant strains and recurrent clinical presentations.

 

 

My focus today was on Mycoplasma Genitalium as it has been a topic of many discussions recently. 

Several presenters discussed this topic

Dr Catriona Bradshaw, Melbourne Sexual Health

Dr Jorgen Jensen, Statens Serum Institute, Copenhagen

Prof. Charlotte Gaydos, John  Hopkins Centre

Dr Lisa Manhart, University of Washington 

Mycoplasma Genitalium (MG) causes symptoms similar to C. Trachomatis & N. Gonorrhoea 

Sequelae in women include pelvic inflammatory disease, spontaneous abortion, preterm birth and infertility. 

Diagnosis is limited to NAAT as culture lacks sensitivity and takes a long time. It is however recommended that NAAT testing should include resistance assay.

First line treatment regimes have included azithromycin and doxycycline, individually or in varying combinations, but doxycycline has a low efficacy rate and macrolide resistance has developed after 20 years use of azithromycin for other STI's. 

Moxifloxacin has been used as second line treatment but the past 10 years has seen emerging failure rates in some countries with rates as high as 15% in Asia-Pacific regions. Recent warnings from FDA and Europe, high cost and side effects make this option unpopular.

Funding for testing and trials of new classes of antmicrobials include

* solithromycin

* lefamulin

* diafloxacin

* zoliflodacin

* gepotidasin

The emergence of dual class resistance to both macrolides and  quinolones means there is no highly effective class of antimicrobials currently available to treat  MG. 

Prof. Basil Donovan from the Kirby Institute Sydney in his discussion of treatment of chlamydia, advocates for alternatives to azithromycin. This concerns me, as my experience in a sexual health clinic is that poor compliance is a major factor for using single dose treatments. I hope that new antimicrobial treatments will include single dose. 

 

Evolution and global spread of resistance in STIs- a very useful and insightful topic and very relevant working clinically in the field of STIs. 

The session started with Dr Magnus Unemo who presented ´Evolution and global spread of resistance in Neisseria Gonorrhoeae´. Antimicrobial resistance (AMR) has mostly emerged in post- modern times due to both SNPs and recombinations. Specific linegaes are more prone to develop resistance and remain susceptible.  Extended spectrum cephalosporin (ESC) resistance has emerged from Japan as highlighted in the paper by Shimuta et. al 2015 (BMC Infectious Diseases). Genotype 1407 has accounted for most decreased susceptibility to ESCs worldwide. Most microbial resistance is due to use or misuse of antimicrobials. AMR is a global concern requiring enhanced surveillance, need for new antimicrobials and development of a vaccine is crucial.

Dr Catriona Bradshaw discussed ´Evolution and Global Spread of Resistance in Mycoplasma Genitalium´.

Mycoplasma Genitalium (MG) is a fastidious and slow growing organism making NAAT the only diagnostic solution (difficult to culture). Treatment options are limited as mycoplasma lack a cell wall and are unaffected by many antimicrobials.

Doxycyline is used as first line treatment in many areas of the world but it exhibits low overall efficacy with cure rates of 20-40%. Azithromycin however is widely recommended as first line treatment but there has been a notable decline in efficacy over the past decade. Selected macrolide resistance has been demonstrated, at least 10% of the time following 1g of azithromycin. 

Widespread use of azithromycin for syndromic management of STIs has likely contributed to resistance. Prevalence of resistance is worse in the Asia Pacific region.  Prevalence of resistance to azithromycin appears to be less in countries that preference doxycycline for 1st line treatment of MG.

Moxifloxacin is most commonly used as 2nd line treatment in NG. The recommended dose is 400mg daily for 7-10 days. However in 2007 there were the first reports of moxifloxacin treatment failures for MG.

The experience in Melbourne has been a 12-15% moxifloxacin treatment failure rate. These treatment failures have been associated with ParC mutations. ParC mutations have been observed at low rates in Europse when compared to the Asia Pacific region.

What is concerning is that dual class resistance is emerging which will have huge clinical implications. The priorities now are review of using azithromycin for STIs and syndromal management, development of new antimicrobials and evaluating the use of exiting registered antimicrobials. This particular talk was followed up later in the day with a session from Dr Jorgen Jensen and a late breaker session which I will blog about later on. 

These particular sessions I feel were extremely worthwhile and will have a huge impact on clinical practice. It reiterated the need to be mindful of antibiotic prescribing and be aware of emerging resistance.

 

Posted by on in Testing and Treatment

I attended a lunch session sponsored by Cepheid regarding rapid STI diagnosis and use of point of care testing.

Working primarily in an Indigenous health setting in North Queensland I wanted to see whether a point of care testing model might be helpful with our patient cohort.

Dr Jeff Klausner started the session off presenting `Utility and applications of rapid, molecular STI testing in hard to reach populations´. The current STI statistics globally are quite staggering; over one million new STIs are acquired globally every day and each year there are 357 million new curable STIs ( CT/NG/TV and syphilis).  There is the rising risk of untreatable gonorrhoea, so much so that the WHO has listed NG as one of the top 3 infections that require immediate action. CDC reports demonstrate that STIS are increasing for the first time since 2006 and CDC STI guidelines indicate that treatment needs to be provided on the same day and directly observed.

Point of care STI testing clearly has demonstrated merit. For the patient it provides decreased anxiety and less patients are lost to follow-up. From a public health perspective there is decreased risk of forward transmission of infection, faster treatment for patients and their partners and decreased antimicrobial resistance. From an economic point of view there is scope to expand clinic capabilities, improve treatment costs and target individualized (rather than empiric) treatment. This was illustrated in the example of the Dean Street Express clinic in London. With the use of PoC testing there is quicker treatment, decreased waiting times and increased testing.

Dr Klausner discussed the rates of STIs in pregnancy and the negative consequences of STIs in pregnancy including miscarriage, stillbirth, preterm labour, low birth weights and increased MTCT of HIV. Currently only 13 countries in the world require routine chlamydia testing despite these known adverse outcomes. Point of care testing was trialled in 7 low-middle income countries and more than 2,200 pregnant women were screened for CT, NG and TV. The result of this trial showed high acceptability amongst patients and high treatment rates.

Dr Basil Donovan went on to discuss ´Implementing molecular POC testing in remote primary care in Australia´. Dr Donovan illustrated the difficulties of health care in remote Indigenous communities including the distance from laboratories, high mobility of the population, delays in time to treatment, high rates of PID and disseminated NG.

The Test, Treat and Go Trial was discussed (TTANGO). This was a cross over randomised controlled trial that compared traditional laboratory testing with point of care testing in a number of remote locations across Australia. Median time to treatment was 0 days for POC testing versus 7 days for laboratory testing. Patients reported that they liked getting their result on the same day, that they could be treated on the same day and that they didnt have to return for follow-up. The patient reported dislikes were that they didnt like ´waiting around´. Staff were also interviewed and expressed that they ´felt like a scientist at times´. The staff reported that the point of care tests were easy to use and interpret and they felt increased job satisfaction. Of course there are challenges to report which included high staff turnover in these communities, the need for ongoing public health surveillance and adapting clinical practice.

The session in my opinion was very useful and insightful and very relevant to my current clinical practice. At the particular indigenous health clinic I work at we have high rates of STIs, high rates of treating emperically and difficulty with follow-up. Point of care testing (if costs are appropriate) may be an option for our clinic to improve treatment rates and appropriate use of antimicrobials.

 

Does Doxycycline Prophylaxis have a future?

The short answer from Jeffery Klausner (UCLA, CA) is; Yes.

Jeffery spoke about the two studies and looked at those results.

Antibiotic prevention is nothing new; Rheumatic fever, travellers (Malaria), Lyme Disease, or Travellers Diarrhoea. 

With increasing Syphilis rates in MSM and the risk of facilitating HIV transmission, Doxycycline Prophylaxis could defiantly have a place.

As we already know, Doxycycline is a narrow spectrum antibiotic that is inexpensive.

Two RCT's were conducted; one study looked at daily 100mg Doxycycline for 30 men over 48 weeks (not behavioural intervention), on average most had 1mg/ml in samples with only a few having undetectable levels (?non adherence) which overall showed good levels.

  • 73% reduction in Syphillis
  • 70% reduction in other STI's (Chlamydia)

Study 2: On demand Doxycycline as PEP. RCT in HIV negative men on 200mg single dose up 24 hours after sex, maximum 72 hours post sex. NB: No more than six pills per week.

  • 70-73% reduction in Syphilis and Chlamydia infections.
  • No effect on Gonorrhoea. 
  • Noted increase in GI side effects, (nausea, GI pain and vomiting), nil adverse events.

Both studies showed great results, but more research needs to be done (Australia is part of a trial at the moment), and concerns around long term safety as well as ?Resistance (MRSA) were raised.

Overall a great presentation looking at the future of condomless prevention of STI's in a time where we have over 6000 MSM using condomless HIV prevention in NSW (EPIC, NSW)

 

Posted by on in Testing and Treatment

Gwenda Hughes (National Centre for infectious Disease Surveillance and Control at Public Health, UK)

Spoke about some STIs that are neglected or under tested for. Primarily she spoke about Trichomoniasis. LGV and Enteric Infections.

TV - Seen very rarely in Australian population - but are we testing enough? A large poprtion of infections are asymptomatic. With a higher prevalence noticed in African and black women in the UK.

LGV - Endemic in Africa, Latin America and Asia. With small numbers seen in North America and Australia.

Recently there has been a resurregence in the reported cases in Europe with 25% of cases in the UK being asymptomatic and 50% of cases in Germany being asymptomatic. 

Germany also found that of the positive CT results in MSM 17% of rectal infections were LGV positive and 15% of throat infections were positive for LGV. I found the throat infections very interesting.

Entric Infections - Shigella, Hepatitis A, Giardia.

Outbreaks in MSM population in the UK - found to be higher in MSM that participated in Sex parties, Chem sex (slamming) and HIV+Ve practising CLAI. Are we missing these infections. We routinely test for Hepatitis A in our MSM population and we have great programs for free vaccination of Hepatits A. But shigella is not routinely tested for and requires testing of stool samples. 

Why are some common STI's neglected over others? 

Gwenda Hughes from the Centre for Infectious Disease Surveillance and Control at Public Health UK spoke about the surveillance of neglected STI's this morning. 

On average every year, there are around 358 million new infections of four curable STI's, which one do you think is the highest number?

Syphilis, Chlamydia, Gonorrhoea, or Trichomoniasis?

6.6 Million Syphillis infections, 78 Million Gonorrhoea, 131 Million Chlamydia and at the highest; 143 million Trichomoniasis.

Caused by the parasite Trichomonas vaginalis, it is nine times more prevalent in women and with the associated risk factors of lower socio economic factors, lower levels of education and increased number of partners.

With poor specificity on wet smears, limited surveillance data, and knowledge gaps in racial ethnic disparity target groups, this is an STI that would benefit further research. 

In Sydney we do see limited infections, and this is more common in rural Australian settings, and higher amount in Aboriginal Torres Strait Islanders. 

Lymphogranuloma Venerum  (LGV) - is commonly tested in Australia with positive rectal CT infections, but one point I thought was interesting the presentation was in Germany that out of 154 MSM with positive CT infection not only had 17% had LGV rectally, but 15% had pharyngeal LGV.

Would this number be similar in Australia with the Sydney study (David Templeton) showing 3 out of 75 positive LGV with rectal CT. 

Could we do pharyngeal LGV testing with positive CT Pharyngeal PCR swabs?

HCV Infections in HIV negative MSM on PrEP

I attended the oral presentation sessions today on STI Surveillance with four different speakers on the topics of

  1. "A tale of two halves, low extended-spectrum cephlasporin and high azithromycin resistance in Neisseria Gonorrhoea in Europe,2015.
  2. Predictors of Persistent and Recurrent genital STI symptoms at sentinel surveillance cities in South Africa.
  3. High Prevalence of Hepatitis C Virus among HIV negative MSM in Amsterdam PrEP project.
  4. Origin and predictors of early repeat infections among HIV negative women with TV receiving a stat dose of 2g of Metronidazole. 

I will speak mostly about the HCV study in Amsterdam, but I just wanted to quickly mention number one. Each topic was around 15 minutes long, so limited time for questions or follow up.

1. Michelle Cole from GASP (Gonococcal Antimicrobial Surveillance Program) spoke about how they are testing resistance to gonorrhoea with Ceftriaxone, Cefixime and on every third year Gentamicin.
- Overall 2134 isolates were submitted from 24 countries and 1 x Ceftriaxone resistance was found.
- Five isolates had high Azithromycin resistance in 2014, and there was a high amount of resistance found in Heterosexual men and MSM compared with females.

Conclusions; high but stable resistance to Azithromycin and low overall resistance to Ceftriaxone and Cefixime. The speaker had raised discussion points around possible resistance; ?Mono Therapy, Azithromycin for NGU or the high use of Azithromycin in general?

-------------------------------

 

3. Roel Achterberg - Amsterdam, spoke about the study looking into HCV prevalence in HIV- men, specifically looking at the PrEP implementation program.

It was discussed that over the years, HCV emergence was noted in HIV+ MSM, not knowing why HIV- men were unaffected, questioning Biological, behavioural or network factors? The research question was asked; Is there HCV prevalence among MSM and Transgender persons starting PrEP, and do they cluster with HIV+ MSM?

Participants had a choice of daily or Event required PrEP (not available in Australia under trial). All were tested with HCV Antibody and HCV RnA.

  • 376 participants 
  • 18 Participants HCV+ (Ab and RNA)
  • 1 RNA+ but Anti HCV Neg, 14 RNA and Anti -HCV pos, 3 HCV RNA Neg anti HCV pos.
  • People with HCV reported more CLARS than others who were HCV negative.
  • Chemsex was a high component.

Conclusion from the speaker was that HCV prevalence was higher than previously found with HIV negative MSM.

As EPIC data in Australia is still being collected and reviewed by the Kirby Institute, it will be interesting to see how our data compares to Amsterdam.

I spoke to Roel after the presentation and asked about continual testing and study with PrEP and if they noticed behavioural changes or rates of infection throughout PrEP, but this data was still not available for them also.

 

During lunch I attended a Roche sponsored integrated symposium titled ´Syphilis, Chlamydia, Gonorrhoea-Oh My: Diagnostic Advances, Hurdles and Considerations.

I used this opportunity to get a refresher on syphilis considering the rates we are experiencing in North Queensland and to see whether trends/testing/management vary in other parts of the world. It was a very informative talk and definitely made me consider other presentations of syphilis i.e chancres in non-genital sites ( fingers, tonsils etc).

 

Dr Marco Cusini of the University of Milan, Italy presented ´Current Trends in Syphilis Testing´. The landscape of syphilis in 2017 is that it is well and truly still present and a major public health problem. Late syphilis is rare in Europe but early syphilis still very prominent. Thankfully it is still highly sensitive to penicillin G. In terms of clinical diagnosis, syphilis can be difficult as it is `the great imitator´. Sites of the primary lesion can be extra-genital (and unusual locations), the morphology of lesions can be challenging and there may be a number of primary lesions. Occular involvement also needs to be remembered! 

The diagnosis of syphilis can be achieved through direct methods if lesions are present. This is a quick and in-expensive method but only useful if used under expert eyes. NAATs have the highest sensitivity and specificity. Serology needs always to be performed to confirm the diagnosis and for ongoing disease follow-up. 

Point of care testing are useful in developing countries and there is one FDA approved test. POC testing for syphilis shows good specificity and sensitivity but Dr Cusini stated that they were not really a substitute for serological testing if laboratory facilities are available.

Lumbar punctures need to be considered in anyone demonstrating signs or symptoms of neurosyphilis or demonstrating occular involvement.

Adequate response after treatment was discusssed. Generally an adequate response after treatment for active syphilis is considered a 4 titre decrease at six months. It was good to hear that at our clinic we follow similar guidelines.

Dr Cusini referred to the 2014 European Guidelines for the Management of Syphilis (Janier. et al, 2014) for further information regarding diagnosis and management. It is easily found on the web should anyone wish to read it.

Definitely a good refresher on syphilis and an interesting lecture.

 

Point of care testing - is it the way of the future? Dr Tarim Sadiq (St. George's University of London) Spoke about new POC testing technologies currently used and some that are in the pipeline of development. 

Dean street Clinic in London are currently utilising the GenXpert POC tests where results are available in 90 minutes. However most clients do not want to wait in the clinic for 90 minutes. Available now and with more in the pipeline are a new generation of POC tests where results will be available in under 30 minutes. Meaning that clients can receive treatment at the initial consult if they have a positive test result. 

In the not to distant future POC tests that can test for CT. NG. MG and TV will be available. And resistance testing for NG and Macrolide resistance in MG will be available in the POC Tests also. 

So what are the barriers to implementation of POC tests. And is there a space for their use in Australia. 

Firstly the COST - In Australia in the sexual health clinic setting we have access to tertiary hospital laboratories. Do we need to outlay more money for POC tests to be available  in the clinic setting?

And what are the public perspectives in relation to POC testing - are they open to the idea of using POC tests or do they want conventional laboratory tests thinking they are more accurate?

The talk at the conference is that POC tests are the way of the future, How we integrate them into our practice is another question.

The exciting thing that I believe comes from POC testing is that resistance testing for STIs will be available quickly meaning the right medication can be used first go. 

Thoughts? 

 

This morning started with a great presentation of two Plenaries, starting with Vaginal Microbiome Research by Jeanne Marrazo - ISSTDR President and Professor/Director of Infectious Disease at University of Alabama - Birmingham. The Plenary followed was PrEP implementation, covered by my other colleague, Tamara. 

Jeanne spoke around the importance of healthy vaginal Microbiome and the increased risk of acquiring HIV/STI's. Some of these topics are already known, but it's good to re visit the importance of education to clients and to increase health literacy.

The benefits of having an optimal vaginal environment will see lower levels of HIV in women, protection from pathogens such as Bacterial Vaginosis (BV), Chlamydia, Gonorrhoea and TV as well as optimal birth outcomes such as a normal birth weight, timing of delivery and fewer pregnancy associated infections.

What is optimal vaginal environment? <4.7ph is optimal and anything above would be consistent with BV, in line with other symptoms (NB: STIPU Australia say >4.5ph).

Jeanne discussed that overall, women with BV have a 60% higher risk of acquiring HIV through vaginal sex, and men who's female partner is HIV+ are more likely to acquire HIV if those women have BV. On this note, Jeanne also mentioned that yes BV is quite common in Sub Saharan Africa, and can considered "normal" but it's not optimal.

In conclusion, further research is needed and more data around HIV/BV transmission risk to women. An important point was raised at the end around PrEP (TDF/FTC) implementation in women, especially around vaginal mucosa versus rectal being less effective in early administration and also studies are showing Tenofivir can have reduced coverage when Gardnerella Vaginalis is present.

The second plenary by Sinead Delany-Moretlwe (blogged by Tamara) spoke about Tenofivir effectiveness in women and it showed a lower tolerance for missed doses in the female genital tract in comparison to protection in rectal tissue acquired much sooner. 

With PrEP studies in Australia mostly recruiting MSM, it's interesting to look at female vaginal health in relation to PrEP, considering future prescribing options and the importance of education around HIV risk, STI reduction strategies.

The day started with a presentation from Prof. Jeanne Marrozzo, Professor of Medicine and Director of the Division of Infectious Diseases, University of Alabama, Birmingham.

Key points - 

* colonisation of a newborns gut is dependant on the type of birth

       ^ Caesarian births result in the newborns gut being colonised with skin flora eg staph aureus

       ^  Vaginal birth results in the newborns gut being colonised with healthy lactobacillus     

       ^ With the high rates of Caesarian births in developed countries, the practice of introducing the mothers           vaginal secretions into the mouth and nose of the caesarian born neonate may need to be seriously considered.

* Women with Bacterial Vaginosis (BV) have a 60% higher risk  contracting HIV through vaginal sex

* HIV neg men whose HIV+ female partner has BV are more likely to contract HIV

* one outcome of the VOICE study revealed that women using tenofovir vaginal gel who had a lactobacillus dominant vaginal biome had a lower risk of contracting HIV, compared to those with a lactobacillus non-dominant vaginal biome.

* maintenance of a healthy vaginal environment might reduce the risk of contracting STI/HIV, further research is required to establish how this is achieved, particularly to establish the pathogen that causes BV

The afternoon continued along the vaginal microbiome theme with several presentations:-

Dr Ricardo Diaz, University of San Paulo Brazil

* Gardnerella Vaginalis reduces the levels of TDF-DF in vaginal fluid

Olimade Jarrett MD

* The presence of P. amnii and S. sanguinegens in vaginal miceobiome was associated with a 3.5 to 4-fold increase in rates of Trichomonas vaginalis infection

Charlotte Van Der Meer

* The Dutch study on Effect of intra-vaginal douching on the vaginal mucosa suggests that use of intra-vaginal douching has no effect on vaginal microbiome, but may increase the risk of developing a candida infection. 

Such an exciting area of research, where so much more knowledge is needed to reduce risks of acquiring HIV, STIs, and those pesky vaginal conditions. 

Dr Sinead Delany-Moretlwe presented a plenary regaring the implications of implementation of PrEP.

In November 2015 the World Health Organization recommended that PrEP be offered to high risk individuals. This was based on key evidence of 12 randomized controlled trials of oral PrEP effectiveness. PrEP was found to be effective at reducing HIV across age, gender or mode of HIV acquisition. The caveat to this was the effectiveness of PrEP depended on the level of adherence.

The greatest impact and cost effectiveness of PrEP will be in populations where HIV incidence is >3 per 1000 person years.

As a result of the WHO recommendations truvada as PrEP has been approved in more than 17 countries and just recently has been approved in Belgium, Portugal, Brazil and now the UK. US data of retail pharmacies has shown a dramatic increase in the rates of PrEP prescribing. There has been a 738% increase in prescribing since PrEP was recommended. UNAIDS has estimated that >160,000 people globally are currently on PrEP. However the targets set for those on PrEP by 2020 is 3 million people.

So what does PrEP offer for the patient? Decreased anxiety, increased disclosure amongst partners, increased intimacy and trust and increased self efficacy.

However there are significant barriers to PrEP use and these involve stigma surrounding its use. Other perceived barriers include:

1.) Safety in terms of side effects and effects on bone/renal health

2.) Resistance

3.) Longer term follow-up

4.) Development of safer drugs

5.) Potential effects in pregnancy and breast-feeding

6.) Cost especially if public funding is involved

The key questions to implementation include- how do you create demand? How do you supply demand? How do you support effective use?

Certainly many of the challenges can be seen as opportunities to strengthen and revitalize sexual health services for those most in need.

 

Dr Kevin De Cock delivered an insightful keynote lecture which has set the tone for what should be a very valuable conference. 

He presented the lecture titled " HIV, STIs and evolution in global health". Global health involves a a complex interplay of many different facets and although gains have been made in some areas, there is still unfinished business to contend with. These include finding a cure for HIV, vaccine development for HIV, TB and malaria and shorter answer simpler treatments for TB. 

In terms of STIs there are changes and goals to be achieved. This was highlighted with the numbers of cases of syphilis, rising in the US since 2001.  Of these increased numbers the majority of those affected are men, particularly MSM. Rate of congenital syphilis have risen by 35% ( did I hear that right?!) since 2013. What are we doing to decrease this burden? How did this happen? Is screening for syphilis occurring where the burden is highest?

Clearly there is no easy solution to these issues however it was concluded the forging alliances, stronger networks, deeper epidemiology and stronger science are part of the answer.

A very thought provoking keynote lecture....

 

 

The new WHO STI Treatment Guidelines were released August 2016 after 3 years of a very complex process, this was the first update since 2003. The recommendations were mostly based on very low - low quality levels of evidence but resulted in 'Strong Recommendations' or 'Conditional Recommendations'. 

Target populations were based on the same as Australian target groups but I was surprised to see the adolescent group include 10 - 19 year olds compared to Australia's young people aged 15 - 24 year olds. 

N. Gonorrhoea 

Recommended treatment 

* 250mg ceftriaxone IMI + 1gm azithromycin oral stat

When asked why 250mg ceftriaxone IMI as opposed to 500mg ceftriaxone IMI as recommended in may developed countries including Australia, Prof Magnus Unemo explained that there were no adequate RCT to support the larger dose worked any better than the recommended. 

Also they advised a 'Strong Recommendation' for all neonate to receive prophylactic treatment for prevention of gonococcal and chlamydial ophthalmia neonatorum, a practice abandoned in Australia with no subsequent increase in occurrence of infection or childhood blindness.

C. Trachomatis

* Azithromycin or doxycycline remain the treatment of choice for CT

* Anogenital CT - treatment changed to 7/7 of doxycycline 100mg BD.                                                                       Australian STI Guidelines recommend 7/7 of doxycycline 100mg BD if asymptomatic and 21/7 if symptomatic

Prof. Nicola Low advocated that the doxycycline regime of 7/7 of treatment still cures CT as well as if not better than azithromycin even if the course is not completed in non compliant people. 

* There is no evidence that repeating or lengthening the course of treatment is any more effective. 

Syphilis

* Nothing has changed in Rx recommendations for syphilis

* There is very low quality evidence to support the recommended treatment

* Treatment is based on 70 years of successful treatment.

I enjoyed Dr Francis Ndowa's analogy that there were no RCT proving the use of parachutes when jumping out of a plane greatly improved survival over not using one, so proving benzathine penicillin successfully treated syphilis didnt require RCT. 

* There is a pending global shortage of benzathine penicillin so alternatives include

        * doxycycline, ceftriaxone and in special circumstances azithromycin 

Genital Herpes

The only change recommendation for treatment is to increase treatment of the first outbreak of genital herpes to 10 days as most first outbreaks are prolonged. 

WHO STI Treatment Guidelines 2017

 

Good morning from the 2017 HIV/STI Conference in Rio De Janeiro. There may be a cross over in some topics with other ASHM bloggers but over the course of the congress we will be blogging about different items.

This morning commenced with WHO treatment updates and guidelines, which had not been updated since 2003. The WHO updated guidelines and their objectives focused on ensuring they have international guidelines for the effective treatment of Neisseria Gonorrhoea, Chlamydia Trachomatis and Syphilis.

The majority of all treatment guidelines have already been adopted by Australian STI Management guidelines (STIPU) and are in place, but the key points taken will be outlined below.

* Neisseria Gonorrhoea (Assoc. Prof. Magnus Unemo - Director Swedish Reference Lab) - Dual Therapy (Ceftriaxone 250mg IMI with Azithromycin 1g Oral) recommended in all cases (Ano-Rectal, Oropharyngeal and Genital), unless resistance to Azithromycin is known, then single therapy with Ceftriaxone 250mg or Cefitixime 400mg can be used but again this only in specific cases and specialist advise should be obtained.
NB: STIPU do recommend 500mg Ceftriaxone IMI as do a number of other clinics worldwide. 

- Reinfection is treated again with dual therapy, but consideration could be given to treat with 500mg Ceftriaxone IMI with 2g Azithromycin Orally.

* Chlamydia Trachomatis (Nicola Low - University of Bern)

Guidelines were again similar to what STIPU guidelines in Australia recommend with a strong enforcement around Doxycycline versus Azithromycin in Ano-Rectal cases.

- 1g Azithromycin oral for Uncomplicated genital infections or Doxycycline 100mg Oral twice daily as alertantive treatment.

- Ano Rectal infections, there was a important point about ensuring Doxycycline 100mg BD for 7 days was used as first line treatment, and that Azithromcyin not be used as a treatment option. 

- For LGV, Doxycycline 100mg BD for 21 days is now recommended treatment versus the previous 14 x day treatment. 

- An important change from the 2003 guidelines was that Erythromycin was considered first line treatment in pregnancy, but now Azithromycin is the recommended treatment for women with a Chalmydia infection during pregnancy.

It should also be noted that Nicola Low mentioned there was not enough evidence for Azitrhomycin extra dosing to be used to treat Ano-Rectal Chlamydia as previously done for patients who might have had issues with Doxycline dosing adherence.

Treponema Pallidum (Syphilis) - Dr. Francis Ndowa (Zimbabwe).

Australian STIPU guidelines already reflect current guidelines.

- Early Syphilis -  2.4million units (1.8g) Benazthine Penicillin IMI as a single dose is still recommended as first line treatment or Doxycyclinne oral 100mg BD for 14 x days if there is a Penicillin allergy. 
(NB: Numerous other alternatives given, but not enough information was transcribed to write about)

- Late Syhpilis (>2 years) - 1.8g Benzathine Penicillin IMI as three doses spilt into 3 x weeks (i.e.: Every seven days), which is current to Australian guidelines. 

Genital Herpes Simplex Virus (HSV) - Prof. David Lewis - (Australia).

19.2 million new HSV2 diagnoses in 2012 for people aged 15-49 (11.3% Global prevalence)

6 x recomendations which show commence treatment straight away on first initial episode. Evidence showed a reduction in symptoms 2-4 days less than placebo and HSV shedding in 9.2 days
NB: See Brett Hadlow's blog for information around medication dosage recommendations).

For cases under four occurrences a year, treatment again is recommended with a 2.5 day reduction in viral shedding.

For cases over four reoccurrences, repressive therapy is recommended over suppressive and a twice daily dose of Acyclovir (400mg) or 500mg Valaciclovir once daily. Evidence showed less frequent HSV occurrence, and reduced shedding.

Overall it was good to see Australia is working within the WHO guidelines to combat STI prevention and ensure appropriate treatment.

For current Australian STI Guidelines, please see http://www.sti.guidelines.org.au

Photo 1: Blogging in my hotel room with Brett Hadlow looking over Barra Da Tijuca Beach.

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This morning saw the kick off of the STI and HIV World Congress in Rio de Janeiro Brazil.

First off this morning was the 2016 WHO Treatment guidelines - last updated in 2003.

Noting that the new guidelines will be released in 3 stages.

 

(A.Prof, Director) Magnus Unemo of Swedish Reference Laboratory

Neisseria Gonorrhoea:

Treatment recommendations for Dual therapy over single therapy.

Ano-rectal and UI-

- Ceftriaxone 250mg and 1G Azithromycin 

- Cefixime 400mg PO and 1G Azithromycin.

Oral N.Gonorrhoea-

- Ceftriaxone 250mg and 1G Azithromycin.

- Cefixime 400mg PO and 1G Azithromycin.

It's of importance that currently in Australian Guidelines 500mg of Ceftriaxone is recommended and the WHO recommend 500mg in it's 2nd line treatment when 1st line therapy has suspected treatment failure.

Representitives from the UK and Europe also stated that are currently using 500mg as first line therapy due to high prevalence of resistance.

 

Dr Nicola Low (University of Bern)

Chlamydia trachomatis 

Take home message- changes in guidelines

- Use of Doxycycline over Azithromycin for Ano-rectal infection.

- 100mg Doxycycline BD for 7 days.

LGV - Treat with Doxycycline 100mg BD for 21 days - was 14 days in previous guidelines. 

 

Dr Francis Ndowa (Zimbabwe, WHO consultant)

Syphilis

Primary, Secondary and Early latent (2 years or less)

Treatment is with (2.4 million units) 1.8g Benzethine Penicillin IMI Single dose.

Alternate Treatment - Procaine 1.2 IU IMI Daily for 10- 14 days.

 

Late Syphilis (more than 2 years)

Treatment is 2.4 Million units Benzethine Penicillin IMI one dose one week apart for 3 consecutive weeks.

In penicillin Allergy - 100MG Doxycycline BD for 30 days.

 

Dr David Lewis (Sydney, Australia)

HSV

19.2 Million new HSV infections in 15 - 49 year olds world wide in 2012.

Recommendation 1 - 1st Episode of HSV infection - treat.

Recommendation 2 - Treatment recommendation Use Aciclovir over Valciclovir or famciclovir.

Dosage 400mg TDS for 10 days.

Recommendation 3 and 4 - Recurrent symptoms treat within 24 hours of symptoms or prodromal phase with Aciclovir 400mg PO TDS for 5 days, 800mg BD for 5 days or 800mg TDS for 2 days

Valciclovir 500mg PO BD for 3 days.

Recommendation 5 - For recurrences of more than 4 per year consider suppressive therapy for 1 year and then reassess. Aciclovir 400mg BD for 1 year.

 

Dr Manica Balasegaram (Global Antibiotic Research and Development Partnership, GARDP)

Spoke about the development of new treatments for STIs and in particular showed a snap shot of a road map for development of new treatments for N.Gonorrhoea with the main goal of new treatment by 2023.

Main goals of accelerating new agents to be used and investigating existing antibiotics that could be used in new combinations. It's exciting to see that we are looking to the future in regards to Antibiotic stewand ship and treatment of emerging resistance.

 

Posted by on in Workforce Development

At the close of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, faculty members Dr. Charles Boucher and Dr. Patrick Chung-Ki Li quickly presented a few slides showing the breakdown of who attended the conference.

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An interesting point (I think) is that as a nurse, many presenters stated that to instigate new ways of working, reaching vulnerable populations and rolling out PrEP, nurses would be the backbone of the work force. Yet, only 5% of the attendees were nurses. To get nurses onboard and understand why they are expected to step up and lead these innovations, more need to attend conferences like #APACC2017.

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Tagged in: APACC 2017

At one particular session of the 2nd Asia Pacific AIDS & Co-infections Conference (APACC) that took place from 1 to 3 June 2017 in Hong Kong, Dr. Dan Kuritzkes (Harvard Medical School, USA) started his presentation by asking the question, 'Why do we need new drugs?'

 

The answers being:

 

  • Side effects of current therapies.
  • Long term toxicities of current ART.
  • Resistance issues.
  • Need for less frequent dosing.

 

He then went on to discuss new medications in development/trials.

DORAVIRINE (NNRTI) — This drug is active against HIV carrying the common NNRTI resistance mutations, it has low potential for drug-drug interactions and has the same efficacy as Effavirenz.

BICTEGRAVIR (INSTI) — Active against wild-type and strains carrying the common INSTI resistance mutations.

Dan went on to discuss the pros and cons of different types of treatment delivery such as injectables.

Pros                                               Cons

Monthly dosing                                 The injection itself may put clients off

More convenient                               Long term tolerability

Less internal stigma                          Long half life

Better adherance                              Cannot be self-administered

An interesting snippet was that TRUVADA is being researched as an injectable. This ties in with Dr. Zhang's presentation who stated that TRUVADA as a single tablet wasnt available in China and called for a new way to deliver this medication especially in the setting of PrEP. Dan mentioned a few other drugs in development but didnt elaborate much on them. These being:

IBALIZUMAB, FOSTEMSAVIR and PRO140.

The summary of Dr. Kuritzkes' session is:

  • There are new drugs in several classes undergoing clinical trials.
  • Different delivery systems are being researched.
  • Novel viral and cellular targets are being explored rather than the traditional classes.
  • 2 Drug ART regimens could became the norm rather than 3 drug ART.

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Tagged in: APACC 2017
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