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

Presentation by Andrew Carr.

Bone loss in 1st year of ART is a well established fact.

Loss is more on tenofovir containing regimes 2.4-3.8%  non tenofovir 0.7-2.5%.

Compare to 1 year 10mg prednisolone 0.8 -3% loss

PREP tdf-ftc

4RTC's show 0.5-1.5% loss BMD over 12-30 months!

          Reversible  if stopped  after 1 year

             Reversibility not established for longer periods, prep may be long term

Proportion of those with greater bone is uncertain

            >3% loss at hip and LSS in 25-50%

Non adherence issues in early RCTs , so bone loss may be underestimated.

Study 36 men taking TDF-FTC PrEP on prelude trialNSW,av age 38, av weight 79.9,TDF exposure pretrial 6months.

Average BMD loss - 2.2 spine,-2.5 fem neck,but,approx 45% lost>3%, 25% lost>5% BMD

Study limitations :no control,no women,some loss attribuible to age, 1 year data only,no PK data

Needs:

Longer f/up, data on secondary causes of BMD loss,more patients to identify risks for the greater loss group

 

 

 

 

Hilary Caldwell from UNSW presented qualitative research that utilised thematic analysis to interpret data from 17 semi-structured, in-depth interviews with sex workers who have female clientele. The participants were self-selecting volunteers who were sourced through their organisations and via Facebook. The participants were from varied backgrounds, genders and geographical locations. The data gathered demonstrated the demographic diversity of female clientele who utilised the services of the surveyed sex workers. According to the workers, female clientele had varied income levels, ethnicities and ages. The female clientele shared similar motivations for seeking these services as male clientele. Motivation was often focused on the women’s safety, the discretion of the professional and the desire to utilise the services of a “sexpert.” The surveyed sex workers made note of the ways in which women buy sex, noting the importance of mitigating risk. Most women counteract this risk by utilising agencies rather than brothels, seeing private sex workers, buying erotic massages and using referrals from other women who buy sex. Making note of the behaviour of their female clientele, the sex workers mentioned that the women were less likely to push the boundaries of the sex worker or haggle for discounts, but were more likely to bring up consent and “check in” with the sex worker during a session. Interestingly, this is the only empirical evidence of its kind in Australia. As the market increases for women buying sex in Australia, it will be interesting to see how the research keeps up with this burgeoning trend.

HIV and the law – a consensus statement

Paul Kidd from the HIV Legal Working Group (VAC and Positive Life VIC) launched a recently published consensus statement about HIV and the law at the ASHM hub during the afternoon break on Wednesday. The consensus statement was written by leading HIV clinicians and scientists and was published in MJA on the 7 November. 


Paul Kidd provided context around the development of the statement and an overview of the key points covered in the statement.

Context
There have been at least 38
Criminal cases related to HIV transmission or exposure in Australia and the rate of prosecutions hasn’t decreased with advancements in treatment and prevention options. HIV-related criminal prosecutions require that legal professionals interpret scientific evidence on HIV transmission risk and the harms associated with an HIV diagnosis. History indicates that scientific concepts may have been inconsistently applied in Australian trials and some people have received very harsh sentences (arguably too harsh).

 

Recommendations
The statement outlines the latest evidence on HIV transmission risk, prevention and treatment. The main points covered in the statement:

       The risk of HIV transmission during sex is very low (and may have been overstated in HIV-related legal cases in the past).

       In addition to condom use, the following should be considered as taking reasonable precautions to prevent transmission:

o   If an HIV-positive partner has an undetectable viral load OR

o   if the HIV-negative partner is taking PrEP

       Phylogenetic analysis cannot prove causation in HIV-related cases.

       Most people living with HIV are able to take simple and effective treatment and will have a normal life expectancy.

 

The statement recommends:

       Legal cases relating to HIV transmission should consider the best scientific evidence on HIV risk and harms

       Alternatives to prosecution, such as the public health management approach, are often appropriate

 

Paul thanked the impressive contributors for their authorship and the wider working group for their commitment to the statement. I was lucky enough to be involved in the development of the statement and it was great to be present for the launch.

 

The statement is available on the MJA website at: https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement

 

A PDF is available on the ASHM website:

http://www.ashm.org.au/hiv/resources 

Brief video created today to help increase knowledge for GP's on DRE exam for MSM.

I hope that it will help increase knowledge and practice within the GP community. I will continue to share response from my GP colleagues as they interact with the video.

Very excited to be able to walk away from this conference with some proactive resources that may help increase knowledge beyond those who attended.

Specail thanks to Dr Ong for this time and expert knowledge.

Learn more here: http://www.anal.org.au/clinician

Martin Holt presented interesting results from the Australian PrEPARE Project.

Overall the results seemed to lean towards willingness to use PrEP being amongst the minority of people in the MSM population, with the willing parties mainly being in the high risk group of contracting HIV.  These high risk men most willing to use PrEP are with those with HIV positive partners and inconsistent condom users.

Interestingly, the study also looked at men who were willing to have sex with a PrEP taker. People in this group were mainly those who were positive themselves, or who had a HIV positive partner, rather than those who are having casual sex with multiple partners. 

Really interesting! I can't wait to see what happens as more people start taking PrEP as it becomes more freely available! Maybe it will become more widely accepted. 

Mondays sessions on contraception and abortion contained many topics and key points I will take back to my work place and will make a difference to the Indigenous communities I work in.  

Living in a remote and isolated setting rules out certain options for local people with regard to abortion and family planning options. Learning of the telehealth options that are now available for early abortions gives young women another choice in this regard. 

I am interested in the future of this particular model and it's evolving service and how it can benefit those living in these remote settings. 

Thursday morning Lisa Fitzgerald presented a memorable overview of patients living with HIV. She outlined the importance of biomedical information, however also stated that real life complexities are sometimes marginalized. 

Living with HIV as a disease is difficult enough, but for those people in the community that have no social or familial support those issues are emphasized. 

I have learned a lot about HIV as an illness, however understanding the linkages beyond the treatment cascade into the day to day social lives have been highlighted again. 

A great reminder to clinicians that a patient is at the heart of these illnesses we all learn about. Thanks Lisa! 

Current criminal law is lagging behind our latest understandings of how HIV is transmitted, and more importantly *not* transmitted.

Take for example law in the Northern Terratory. NT currently hosts a "spitting laws" that can allow for invasive HIV testing in instances of spitting. This is despite zero evidence to demonstrate potential HIV transmission via saliva.  It is clear that current judicial law Is well behind the evidence when it comes to public safety with regards to HIV transmission.

As part of this weeks ASHM conference 2016 a position statement has been launched to help guide law towards the latest research and medical data on the current risks of HIV transmission.

I applaude the release of this position and hope that this may be quickly picked up within our judcial systems moving away from legislation and towards eudcation and health based interventions.

http://theconversation.com/australian-law-needs-a-refresher-on-the-science-of-hiv-transmission-68225

https://www.mja.com.au/journal/2016/205/9/sexual-transmission-hiv-and-law-australian-medical-consensus-statement

 

 

Professor Gracelyn Smallwood 'Aunty' delivered a highly emotional discussion about the realities faced by many Aboriginal People and Communities across Australia.

Most of the Closing the Gap money (75%) is not going to grassroots level of the people.

it is been swallowed up by university research, and provides jobs to non-aboriginal people.

Gracelyn said that poverty is widespread and needs to be cleaned up.

Many don't have running water and sanitation is poor. 

Food is marked up 200%

Most are unemployed and on Centrelink benefits.

ICE/ substance/drug use is high, including injection.

Concerns about HIV reaching remote and rural communities.

High rate of imprisonment  

Aboriginal Health & Community Services need culturally appropriate programs.

Non-Aboriginal people involved in programs deliver need to go into communities before and consult and talk with keys players/stakeholders and elders. 

Local grass root program delivery don't have to cost lots of money,                                                             such as the 'deadly program' and 'grog kills skills' delivered on a  shoe-string budget. 

Gracelyn talked about her us of the (world famous) Condom man.

This health promotion/prevention strategy was used successful and widely as a healthy alternative to the scary 'grim reaper' advertisements to assist combating HIV/AIDS. 

 Non-Aboriginal People need to speak out more and advocate for ABSTI People by keeping it on the agenda.

Australia needs to reconcile with the past and the ongoing injustices against Aboriginal and Torres Strait Islanders People's. 

Please read Gracelyn thesis which she addresses these multilevel issues in Australia's Indigenous People. http://www.atsiwlsnq.org.au/reports/Gracelyn_Smallwood_2011_thesis.pdf

Thankyou Aunty, your inspirational presentation. It was the highlight of the conference for me and together we can all individually and collectively help to improve the health and lives of Australians Aboriginal and Torres Strait Islanders People. 

 

 

 

Day 4- Increasing the demand for HIV testing

Mark Stoove discussed innovative ways to improve HIV testing.  50-70% of HIV transmission among GBM are attributed to undiagnosed infection. There were policy and regulatory changes in 2012, which revolutionised HIV testing in Australia. Rapid HIV testing was introduced and there was an increase in HIV testing in community settings. The uptake of rapid HIV testing has been modest. Barriers may include funding, lack of government subsidy and some services feel testing can be time and resources heavy. The majority of HIV testing continues to occur in primary health care settings using serological laboratory testing

Community based HIV testing services such as ACON provide a comfortable, peer based service which clients find very acceptable.  ACON in Sydney provides a peer based testing model, which is supported by nursing staff. Peer based clinics have successfully attracted first time testers that were classified as ‘high risk’. Rapid HIV testing has increased testing in urban areas but more needs to be done for those living in rural areas. We need to expand the geographical reach of HIV testing. The Terence Higgins Trust provided funding to increase testing in the UK. In a 14-month pilot study over 17,500 testing kits were posted and 10,410 specimens were returned. There was a positivity rate of 1.4% and this testing was welcomed by participants with 97% reporting that they would test this way again. Self-testing kits are available in the UK and the uptake has been excellent with over 27,000 units sold between April 2015 –Feb 2016. Half of the test kit users have never had a HIV test before.

Key messages

-We need to ramp up HIV testing

-Self testing kits should be available in available

-Funding may be a barrier for services offering HIV testing. Government subsidies could improve rates of HIV testing

 Vickie Knight spoke about the effect a[TEST] clinics has had on HIV testing among gay and bisexual men. It was found that the clinic on Oxford Street in Sydney has increase testing and also increased the frequency of testing. Factors that make this clinic user friendly include short wait times, the service is free, CASI is used which means intrusive sexual health histories are not taken by health professionals.

 

Key messgaes

This model works and has increased testing among GBM.

 

This presentation by Doris Chebo looks at the risks of the change of thinking towards pushing for treatment as soon as possible after HIV diagnosis from the point of view of current Victorian baseline HIV drug resistance profiles .

The aim of earliest possible treatment is to limit risks of disease progression and reduce HIV transmission, both very worthwhile ideals .

Levels of transmitted drug resistance mutations were reviewed looking at standard drug resistance genotyping in 1356 samples from 2011 to 2015. These included new 

As expected, protease and integrate inhibitor regimes had the lowest level of potential resistance (<1%). Potential resistance to NNRTIs was higher at 4.6%.

This brings up the question of whether to start people on treatment before genotype profiles are available particularly where access is more difficult.

The study was pretty reassuring for us, in that these seem like only  small number of patients had significant drug resistance to our usual ASHM recommended first line treatment regimes.

 

Quick update on a presentation by John McAllister

 

  • if source VL is undetectable, then PEP is no longer recommended
    • however, do need to discuss the reliability of the history of undetectable VL
  • Truvada should be used for PEP
    • avoid tenofovir and lamivudine (although cheaper)
  • 3-drug PEP
    • if 3 drugs are needed, then stick with dolutegravir (ALT increases by 22%), raltegravir or rilpiravine

 

Jason Asselin gave us a comprehensive overview of ACCESS, a national registry designed to pull HIV data from primary health care, sexual health clinic and the laboratory.

 

  • his study included patients who had viral load testing within the last 12 months
    • the last VL for the year was used to allow more patients to be included
    • VL testiong as part of diagnosis was excluded
  • demographics: males were older, females were younger
  • results
    • citeria for undetectable VL was met for 71% (2009) => 87% (2014)
    • porportion of patients with a high viral load decreased
    • similar outcomes for M vs F
    • patients <40 years old were less like to achieve VL suppression compared to older patients
  • weaknesses
    • does not capture patients who did not engage in health service
  • ACCESS will be rolled out nationally from Jul ’16 – Jun’19
    • we can look forward to more comprehensive data

The opening plenary talk was given by Dr Valarie Delpech, who outlined the progress towards attaining treatment for all.

 

  • the UNAIDS target for 2020 is 90-90-90
    • 90% of patients diagnosed
    • 90% of patients on ART
    • 90% with viral suppression
  • data from Levi et al (2016) showed
    • 54% diagnosed, 41% on ART and 32% virally suppressed (2015 data)
  • there appears to be a great disparity in the countries able to achieve this with many having poor rates of diagnosis and hence low rates of treatment/viral suppression
  • Dublin declaration data: EU/EEA countries are performing better than the non-EU/EEA
  • to date, no country has met the 90-90-90 goal (except claimed by Sweden)
  • a major issue
    • most countries have very little data about actual rates (even 4 decades into the epidemic)
    • there is variation with data sources and quality of definitions/standard methodology

Several sessions of ASHM have compared Viral Load (VL) when patients are retained in care, vs those who don't. This session examines the results of the IEDEA Collaboration on VL in adults and children.

The IEDEA is an International Epidemiological Data Base, which gathers data around the world, grouped into 7 regions.

35,561 adults and 2,601 children (81% perinatal infected) from four regions were examined. They found 90% of adults had VL suppression at 3 years. Unfortunately the children didn't fare so well, with only 70-80% having VL suppression at the same time. Both of these data sets, were people who were retained in care. When people who were lost to care were added to the figures, the rates of VL suppression was much lower.

Conclusion: Adult patients retained in care have good VL suppression. Each region has different rates of VL suppression. The W.H.O. aim for 90/90/90 in children will be difficult as adherence is more challenging in this group.

Start treatment if not already on it.

Normal delivery if VL < 50, planned cesarean section for VL 50-399, add iv ZDU if VL > 400

714 infants born to 527.

No breast feeding.

Mean gestation was 38 weeks, mean maternal age at delivery was 30 years.

87% reported heterosexual exposure as the mode of transmission.

32% of infants were HIV infected after birth at the beginning of the time period studied, reducing down to 1.5% currently.

Maternal HIV diagnosis was made before parturition in 49% at the beginning of the period studied, compared with 98% currently.

In the last 10 years, there have been 11 cases of maternal transmission.

These were primarily cases where the maternal diagnosis was not known, or there were tolerability issues with maternal ARVs.

We have seen a substantial increase in numbers of children born to HIV positive mothers over the last 30 years.

41 sexual health clinics across Australia took part.

Treatment uptake 63% in 2007, 79% in 2015.

Significant reduction in viral load over the same time period for those on treatment.

Female, injecting drug user, indigenous groups were twice as likely to have a detectable viral load on treatment.

Has Australia met the W.H.O. guidelines on preventing HIV Mother to Child Transmission (MTCT)? This session looked at the current guidelines for antenatal care, management and rates of transmission.

As I work with antenatal and postnatal mums, I was interested in seeing if the current practices have had a positive effect on transmission rates. The answer...yes we have met the guidelines and reduced the rate of transmission.

Australian guidelines

1) HIV testing is conducted at the first antenatal appointment.

2) Clinical care of the mother include; CD4, VL, STI screening, starting ART and resistance testing

3) Strategies at birth; ART for the baby immediately, mode of birth decided by maternal VL, formula feeding exclusively. Baby to have HIV testing at 6 weeks and 3 months.

Surveillance of perinatal exposure

Data reviewed for the 30 years 1986-2016. 714 babies born to mothers who were HIV positive.

The rates of perinatal exposures are increasing, however the rates of babies with HIV have dropped significantly.

Rates of HIV testing has increased dramatically, and the exclusive use of formula feeding has also increased.

Conclusion

There has been an increase in the number of HIV positive mothers, but a reduction in the MTCT. Australia meets the W.H.O. targets. Which is fantastic news!

Presentation of PraveenaGunaratnam

Data  from the National HIV Registry

Period 2005 to 2015

Reduced representation of plwha from Sub Saharan Africa, 30/100,000 in 2010,15/100,000 in 2014

Increasing representation from  nth Asia, 2/100,000 in2005, 7/100,000 in2014

Increase in Asian born MSM hiv rate from 6 to 15 % of the total in the 10 year period,43 % overseas born  MSM with hiv born in Asia.

Sub Saharan Africans and South East Asians still have high rates of late and advanced diagnosis app 50%.

IMPLICATIONS

Need to reduce barriers to health care access

Evaluate interventions tailored towards different communities, specially with respect to TasP, prep

Continue to gain epidemiological and behavioural research and monitor changes in HIV related practices, health outcomes and prevalence

322 men

Most likely, in order: gay friends, straight friends, casual partners, immediate family, work colleagues, other family.

52% disclose within 6 months of diagnosis.

Younger were more likely to disclose to immediate family, but not gay friends or casual partners.

More contact with people who had died of AIDS were more likely to disclose their status.

Support from peers was associated with more likely to disclose their status.

Peer support was the only factor associated with employing methods to alter sexual behaviour to prevent onward transmission.

Peer support was the only factor associated with likelihood of disclosure across the board.

Twitter response: "Could not authenticate you."