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

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.

Currently around 88% of HIV positive patients are on ART.

500 HIV + men, 320 confirmed viral suppression for over 12 months, on ART long-term were asked to respond to the statement: “Being undetectable makes it unlikely that you can pass on HIV during unprotected sex.”

Only 25% believed that being virally suppressed made it unlikely that they can pass on HIV.

2 other studies supported these findings.

These are the patients we would expect are the most likely to know that they have low infectivity, yet consistently it appears they don’t.

James McMahon  presented  a study comparing HIV load and CD4 count for people in regular care versus those   with unknown outcomes.

He estimated the study covered 80% of HIV positive patients in Victoria over 3 years in 4 sites.

It involved clinics checked their records to look for transfer of care, deaths and returnees to care. 

Patients who did not return for at least one more VL  within a 9 month period were then contacted.

Retention rates for patients were very good at 92%. 

The study found that those who had unknown outcomes,transfered their care/returned to care or who had irregular VL testing had higher VL and were at risk of worse clinical outcomes and onward transmission.

They found that as a result of doing the study there were improvement in clinic systems to improve retention and keep patients engaged in care This was an unexpected positive outcome from this study.

 

 

Looking at the strength of ACCESS to look at the cascades of care.

National collaboration.

Automated data extractions.

Laboratory network captures 80% of people living with HIV.

De-identified viral load records.

Viral suppression taken to be < 200.

Mean age of patients was around 40 years.

Trends over time saw an increase from 71% to 87.5% of patients with suppressed viral load.

Those under 40 years were less likely to achieve viral suppression.

Similar outcomes in terms of gender.

These data reflect those engaged in care.

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.

Treatment as prevention - if we treated everyone as soon as they became infected, they would not be infectious and over time HIV would go away.

Where are we with our 90-90-90 UNAIDS targets?

This equates to 27 million people on ARVs globally.

Currently we are about 40% of that number.

Testing is difficult for countries like Australia and the UK.

Countries show large variability in the proportion of those on treatment.

Less variability by country in viral suppression of those on treatment.

Treatment guidelines are also inconsistent across the globe, where not everyone has adopted treatment for all.

There is lots of data missing from countries, and this is very basic surveillance data.

About 20,000 undiagnosed in UK, uptake of testing is poor.

3,000 new infections per year, would be reduced to 1,000 if we met our 90% diagnosed target.

Posted by on in Uncategorised Posts

The positives and negatives of porn: an overview of the evidence.

The focus is more around young people and heterosexual.

Average age to first see porn is age 13 for males, and age 16 for females.

Most men were watching porn at least weekly.

Gay porn contains a lot more condoms.

Men receiving oral sex much more commonly than women.

Young people report learning about sex through pornography.

Learning about sex was particularly reported by same-sex attracted individuals.

Not wearing condoms and STIs are linked to pornography use.

Women watching porn is often seen as a good thing for a relationship.

There are reports of pornography addiction but there is little evidence to support this, relying mainly on sporadic case reports.

People who are violent are likely to both perform violence and watch violence in pornography.

Body image - little research here to support anything.

Most research is poor quality, out of date, doesn’t look for causation.

Most look for harms, and if you don’t look for a benefit you’re not likely to find one.

Some people feel pressured into doing what they see in porn.

Most people in the industry will get one or two infections per month.

Same-sex porn can be limiting in terms of the stereotypes presented.

What benefits are there to porn?

A partner with a higher sex drive can have an escape, rather than pestering the other partner or seeking sex elsewhere.

Sex acts can be normalised, allowing them to feel comfortable with doing them.

Technically porn is not legal in Australia (hosting cannot be on Australian servers)

It is not legal under the age of 18 years.

Filtering can be applied by governments, parents, internet service providers, but there are problems with censorship - sexual health sites tend to get blocked for example, and other people’s opinions determine what you can watch.

If we had good sex education maybe people might seek out pornography less often.

It’s going to be around for some time, and everyone has an opinion about it.

Perhaps we need some way of being able to talk about it.

Looking at disclosure that one is on PrEP to potential partners and changes in sexual practices.

Interviews with 24 gay men were conducted.

Normalisation.

It can reduce difficulties in disclosing either partner’s status.

Disclosing to presumed negative partners didn’t always go well, probably because I was a bit too intense about it.

Being on PrEP gave them a feeling of not needing to disclose, which was quite welcome.

Reduced sero-sorting, sero-positioning, and sero-withdrawal.

There is more of a fluidity of where the sexual encounter may end up, and less of a script to read from.

There was a reduced concern/worry about HIV.

HIV meds could be seen as something that can enhance our sexual experiences.

Australia is leading the world in PrEP roll out, the numbers on PrEP are amazing.

40-50,000 new infections per year in US, disproportionately in MSM and blacks.

2012 the story begins.

25% of MSM aged 15-59 are PrEP indicated, that’s 1.5 million people.

25% of new infections are in whites, yet 75% of those on PrEP are white.

With 40% coverage and 60% adherence, we estimate one third of infections could be avoided.

It is important to bridge gaps between PEP and PrEP as it is common to acquire HIV meantime.

“The case for PrEP, or how I stopped worrying about and started loving HIV-positive guys”.

No evidence to indicate lower PrEP efficacy in the presence of STIs.

Those with the most STIs are the ones most likely to benefit from PrEP.

We can think of new ways for STI prevention.

“We did not come here to fear the future, we came to shape it.”

Novel delivery methods - people are getting PrEP from all sorts of places

Individuals who are younger with normal renal function have very low rates of renal compromise to the point where it doesn’t require monitoring.

Individual benefit as well as prevention benefits.

But do they really need to start that day, or does a few weeks matter?

Rapid intervention in the US combined the first few visits into one to initiate treatment earlier.

Of 227 patients in a clinic 39 underwent rapid initiation.

70% of participants had acute HIV.

All had no insurance.

90% opted to start ARVs on the first day.

1 in 4 required a change in their ARVs within the first 18 months compared to none who were not recruited on to rapid intervention.

The rapid intervention group still had to attend multiple times for a variety of reasons.

High dropout rates in the rapid intervention group.

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

 

 

Day 2: No Question Too Awkward for  Nurse Nettie

 

Day 2 Rapid Fire Sessions: Health Promotion and Education

 

Carolyn Murray (on behalf of Gemma Hearnshaw) – NSW STI Programs Unit (STIPU):  "No Question Too Awkward: Nurse Nettie, the Online Sexual Health Nurse".

 

Nurse Nettie is a confidential, virtual online sexual health nurse created to allow young people to email questions they may have about their sexual health/sexuality and receive an answer from a sexual health professional within 24 hours (although Nurse Nettie does have weekends off!)  Nurse Nettie was created to address the concern that young people may be too embarrassed or afraid to ask a Doctor/Nurse or parent/caregiver questions about sexual health.

 

Nurse Netttie does not provide diagnosis online but instead refers on to the most appropriate service where indicated.

 

Nurse Nettie commenced in April 2014 and the data presented was up until March 2016. In this time Nurse Nettie had received 761 questions with 77.4% of these being from people aged <30yrs.  Approximately 52% were from NSW and 17% were from abroad. 

 

Common question categories are listed in order below:

 

STI/HIV risk – 14%

 

Anatomy – 12%

 

Symptoms – 11%

 

STI/HIV testing – 10%

 

Contraception – 8%

 

In conclusion, Nurse Nettie has been shown to allow large numbers of young people to receive information about their sexual health in a confidential, personal and specific manner.

 

Nurse Nettie can be accessed at: https://playsafe.health.nsw.gov.au/ask-nurse-nettie

 

This session on Wednesday morning was entertaining and informative. 

It outlined that health promotion is imperitive and very effective in the music/concert arena, sporting events as well as online via dating sites and various other informative websites. Great results have come from increasing accessibility and anonymity of access to both education and screening tools. 

The importance of clinicians and educators utilising an 'as required' method of health promotion and screening programs rather than a blanket, one size sits all approach was emphasized.

Very interesting to hear about various communities and audiences success rates with their various approaches. 

Thank you to all of the passionate presenters! 

 

Notes from talk:

The most recent syphiils outbreak in northern Australia highlights the vulnerability of this community due to isolation, reduced access to services and poor engagement with the health communities. 

Advances in HIV treatment in Australia has created an obvious divide with increased HIV diagnosis in ATSI communities. While non ATSI HIV diagnosis are mainly in men who have sex with men, this only accounts for 50% of the case load in ATSI communities.

Increased IV drug use appears to be fueling this with reduced access to programs such as needle exchange.

Canadian modeling is sobering if we continue on this same path.

 

In today's presentations a strong theme came across that we need more data for sexual health services & the effectiveness of STI's in teenage programmes.

HIV is increasing in some populations.

Professor Mark Hayter, UK, talked about the importance of integrating a multidisciplinary approach         in Sexual Health.

That substance use is often predictor in context of higher risk sexual activity/practices/behaviours. 

Alcohol remains to the most significant driver, which equates to more sexual partners.

Evidence has shown that Clinicians need to identify higher risk individuals and interactions around substance use need to be more substantial, such as motivational behaviours skills. We may also need to consider bring in a Specialist in Drug and Alcohol/addiction, or refer on to another service if the expertise is not available in the service delivery model. 

 

CHEMSEX - MSM sexually disinhibiting drugs use, often with Viagra. 

Potential sexual Partners meet on line, App's - meeting up sites. 

Increased numbers of partners. STI’s risks increased 

PrEP is available option, but also need to address chemsex behaviour. 

Behaviour modification interventions such as education and prevention can reduce changes in behaviour, in drug use and unprotected sex & which reduces the risks of considerable harm. 

Evaluating 1 stop shops for (sexual health clinics) and the effects on staff. Research has shown mixed results of this. 

Need to build research into service design and evaluation with partnerships with Universities. 

 

Reaching out to Schools - Sex Education & relationships:

Nursing is best suited to deliver this care in outreach setting such as schools.

Nurse lead sexual health, mental health and substance use & care delivery to schools children and adolescents, is better delivered and protective under a broader health objectives, as a sexual health clinic at schools will become political. 

 

 

 

James Ward presented evidence about the increase in HIV notifications in Aboriginal communities in 2015- 38 cases. The rate of diagnosis has more than doubled in 1 year. HIV is increasing in remote communities. There has been an overall increase in HIV testing, especially in MSM populations but more needs to be done to increase testing and promote treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP) in Aboriginal communities.Ward stated that the syphilis outbreak in Northern Australia is a national shame with over 900 new infectious syphilis cases and 3 neonatal deaths.Harm minimisation services such as needle syringe programs should be expanded. In the past 5 years there has been a 43% increase in hepatitis C diagnosis, which are largely attributable to injecting drug use. Young Aboriginal clients are particularly at high risk.

Key messages

-HIV testing should be offered as part of a routine sexual health screen

-Community engagement is needed to improve the uptake of TasP and PrEP

-Timely surveillance data is needed.

-Some GPs may not be offering full BBV/STI screening as the consults may be lengthy. Work is underway to Medicare items specific toBBV/STIs

-More NSPs are needed

 Caitlin Douglass from the Burnet Institute conducted study on the sexual behaviours and Tinder usage among young Australians.

Tinder was found to be the most popular dating site. An online study of 1001 revealed that 690 participants had been sexually active in the past year and 40% (266) had used Tinder in the past 12 months-35% women and 45% men. Douglass questioned whether Tinder could be used to promote sexual health services and noted that there was a lack of sexual health content on dating apps. Grindr is the exception as there are ‘sexpert’ willing to offer health advice at the click of a button. Grindr also has a portal which can advise users of their nearest sexual health clinic.

Gemma Hearnshaw of the NSW STI Programs Unit discussed the Playsafe website. Playsafe is an interactive engagement tool, which can inform young people about safer sex practices and testing. Peer educators are trained to deliver informal education to festivalgoers and provide free condoms and advice. There has been repeat exposure of safe sex messages on the Ticketek and Live Nations website.

Viv McGregor grabbed everyone’s attention with the fabulous music video –Close: Lady Sings it better. This playful video leaves room for the imagination. I would recommend everyone have a wee look! Click on the link below.https://vimeo.com/157020994

Research by Albury and Noonan in 2001 revealed high levels of same sex sexual interactions among women, despite the fact women often identified primarily as heterosexual. The study found that there was often a lack of sexual health knowledge among this group and they often participated in riskier sexual practices such as impact play, blood play and fisting.

Key messages

More targeted, culturally appropriate information is needed. Clinicians should opportunistically invite all patients to complete sexual health screening irrelevant of sexual orientation or practice.

Claude packs are available in NSW-‘Play packs’ and ‘Blood Play Packs’.  More information is available at www.iloveclaude.com

Alison Coelho spoke about a comic based resource for young people from refugee and migrant backgrounds. It was acknowledged that change and unsettlement can cause huge upheaval among this population and many people accessing their services have had significant interruptions to their education. It was found that there was limited information regarding sexual health and a surprisingly high number of young people accessing the service had participated in transactional sex.75% of humanitarian intake is young people and a large proportion are young males. They are often unaccompanied minors and often do not have female role models in their family. Sexual health is often not a priority for this marginalised population group. Issues like housing, employment and language acquisition often seek precedence over sexual health information.

The SHARE project has published many cartoons with important sexual health information messages with little written dialogue. Fact sheets are also available.

Key messages 

This website is a must for people working with young people. Check it out @ www.ceh.org.au

Posted by on in Testing and Treatment

The Empowered patient by Lance Feeney,Positve Life NSW, Australia

Factors influencing patients decision making: One of the major factors that influenced patients decision on starting treatment was having a trusted, educated and engaged HIV doctor who explained treatment and care options and provided quality advice. In a survey conducted by positive life NSW 57% would go with above option as one of the most important factor influencing them starting on treatment. Other factors include articles from publications, via internet and community HIV agencies(33%) and advice from other PLHIV (10%)

What makes it difficult HIV? 20% say they have no factors making it difficult to reach an informed decision about HIV treatment and care, however 80% do. Majority worry about its potential side effects, drug interactions with non-HIV meds and their impact on long term use. Other factors include lack of information on new treatments, information being too technical and difficult to understand. there were a few who did agree that the Stigma and discrimination associated with HIV itself is an independent factor that will influence their treatment and care.

 It was interesting to know that patients rather preferred Drs with professionalism( open, motivated, engaged, non-judgemental and listens and discusses issues) and a relationship built on mutual respect, trust and confidentiality over Drs with competency (educated and up to date with HIV care and the management of otherb health conditions).

Day 3 – Joint Symposium Session: Prevention of Anal Cancer in gay and Bisexual Men: The Current State-of-Play and Future Directions.

“What should we be doing for our patients now?”  Dr Jason Ong, Monash University, The Alfred – Melbourne Sexual Health Centre, VIC, Australia

Dr Ong acknowledged the HPV vaccine as a game-changer in the prevention of HPV-associated anal cancer however there is still a cohort of males who remain unvaccinated and therefore will continue to be at risk of anal cancer for many years to come.

Many ask the question: if screening for cervical cancer using the PAP smear works so well in early detection of cervical pre-cancerous lesions, then why can’t we take this methodology and apply it to anal screening of MSM for pre-cancerous lesions (aka ‘CHAP smears’)?

Some similarities and differences between anal and cervical anatomy and lesions were described:

Similarities:

-       Both have transformational zones

-       HPV responsible for a significant proportion of pre-cancerous changes

-       Pre-cancerous lesions are histologically similar

Differences:

-       The anal canal is a much larger area to swab (approx. 5cm tube)

-       It is more difficult to visualise anal lesions

-       Natural history of lesions between each site is different (up to 30% of anal smears are positive for abnormal changes)

-       Progression of changes is different as many more anal intraepithelial neoplasia (AIN) resolve over time compared to cervical intraepithelial neoplasia (CIN)

-       Different referral rates (only approx. 3% of cervical PAP smear result in onward referral for colposcopy but up to 60% of men undergoing anal screening would need referral due to the increased rate of high grade anal lesions.  This has implications for the workforce as it does not have the capacity to deal with such a large volume of referral for anoscopy or further investigation). 

High-grade anal intraepithelial neoplasia (HGAIN) regress at a rate of 36/100 person years so if left alone, many would disappear.

In answering the question of whether we should screen for early anal cancer, Dr Ong explained that the best annual screening tool for MSM would be the digital anorectal examination (DARE).  As approx. 50% of anal cancers are externally visible and approx. 2.9cm in size, and due to the fact that many HGAIN resolve spontaneously over time without intervention, DARE is a most cost-effective and simple early detection technique.

In another study, Dr Ong also explored the acceptability of a DARE for men with favourable findings.  82% of men felt relaxed during the procedure and 99% were willing to have another DARE in a years time.

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As a side note, Dr Ong will be conducting a teaching session on Friday 16th Nov from 10:30am-11:00am using his plastic bum segment for this wishing to perfect their DARE technique …sadly I will miss out!

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