Virtually there

The experience of a virtual conference (live!!) was odd. The main down side was the lack of interaction and ability to dicsuss sessions and data, ask questions and gerenally get a feel of the general response to the speakers. The tech side was fine but many of the speakers were really fast- mainly as they were presenting to microphones rather than audiences.

Still, here are a few bits and pieces that I found interesting. The sti session was mainly epi overviews but the syphilis one (Melanie Taylor, WHO) brought up some good points regarding the missed opportunities and how in many circumstances, women in lower socio-economic countries are being left behind. She pointed out that globally MTCT of syphilis was double that of HIV and that antenatal testing was poorly done. Given that benzathine penicillin costs from 0.50-2.50 USD /dose transmission in pregnancy and the most common outcome, still birth, is unacceptable. WHO have launched a dual HIV and syphilis strategy to combat this . Interesetingly, for those of us who have been affected by the ben pen shortage, the reason given was that there are only 3 manufacturers internationally, all in china (API the active ingredient is avail only in china ). Concurrently one moved premises, one was closed due to environmental issues and the remaining one was small and supplies only the local market- hence the shortage. Work underway to prevent this in future includes bolstering the resilience of the manufacturers and investigating alternative agents including oral cefixime (phase 2 trials ).

Steffanie Strathdee discussed HIV in IVDU and the opioid epidemic in America driven by cheap heroin and prescription opiates. This, with the increase in meth use have changed the epi of HIV in IVDU- younger, female and outside urban areas . She discussed the responses have been too late, too slow and have resulted in syndemics of HBV, HCV and HIV, potentially bridging the epidemics into other communities. In most cases, increases in HCV preceeded rises in HIV which could act as a signal for policy makers. Prep use in these communities was abysmal, with one study reporting of PWID 19% had heard of prep, 17.5% were insured and could pay for it, 3.4% had discussed Prep wityh a dr and only 0.1% had taken prep.  In fact, in the USA only 20% of PWID had any sort of treatment at any one time. Studies were looking into treatment for meth included mirtazapine. 
To prep. Bekerman discussed an animal studies of BIC/TAF/FTC for pep– looking at should courses instead of 4 weeks. After studying different doses of BIC, the most successful was 100mg BIC + TAF/FTC given at 12 hrs and 36 hrs post exposure where 4/6 maquaues exposed to SHIV were protected. Next was Dobard with on demand  PEP using TAF/EVG use as either a intravaginal or rectal pill. For PEP use it was inserted 4 hrs post exposure and protected 4/4 macaques with good local uptake into the tissue. Grobler discussed weekly oral islatravir for PEP- with good results and Spinelli introduced a real time test for TDF using urine whixch may be useful in adherence testing. Accurate for dosing up to 4 days prevuous ti testing (half life). 
96 week data from the discover trial was presented looking at TDF vs TAF for use in prep. Unsurprisingly found that bone and renal outcomes were better in TAF (increased BMD, greater decreased in eGFR with TDF) , and that favourable lipid effects were associated with TDF  (TDF decreased in LDL, tot chol and TGS; however overall,  total cholesterol changes were similar in both arms). AEs were similar in both arms and wt changes were minimal (although greater for TAF).  HIV incidence at 96 weeks was 0.16 for TAF and 0.30 for TDF. In all, both worked effectively and the use of either agent for the vast majority of patients will probably come down to cost. 

Colby discussed PREP and resistance in acute infection. HIV baseline testing as workup for prep in Thailand was conducted via HIV Ab/ag and same day prep was offered. Qual HIV RNA on pooled non-reactive specs to identify acute HIV infection. Results were avail in <48hrs and confirmed via quant HIV RNA. Repeat HIV testing was done at 1 month. Nearly 2500 pts started Prep. 7 (1/350) had acute infection at initiation. Of these 7, 5 were positive via RNA; 2 positives via serology at 1 month) [quant testing of stored sera shows that qual RNA sensitivity dependant on viral load. If VL<100 cps/ml then qual RNA was neg]. ART resistance data avail for 6/7 cases. 3/7 had FTC resistance (1xM184I +1x M184V); 4/7 no resistance; 1/7 had NNRTI mutation E138A; no PI resistance; no TDF resistance. Development of resistance seemed to be more likely the longer prep was taken, in particular >4 weeks. There was low risk of resistance if prep taken < 2 weeks. This data has changed practice in this cohort- now, those with high risk of infection are commenced on triple therapy for 4 weeks and when HIV negative status is confirmed at 4 weeks, continue on 2 drug standard prep. This may be an approach to consider for some of our high-risk pts.
Some trans papers:
The transgender session was interesting but a lot of it not applicable to our setting in Australia. Many of the papers highlighted the disparities in health care access, prep, screening, HIV care and so on and the consequently high burden of HIV and STIs in this group. 
Keruly presented a study which HIV was associated with race, location and age in TGW. Not associated with behavioural factors- possible pointing to the fact that if equality in service provision and access to care are provided, health negative outcomes may be minimised. A study (Radix) of TGM in New York revealed low rates of HIV testing (<42% had EVER had a HIV test). Predictors of HIV were sex with CIS gendered men and level of education.  

On a positive note, Lesko presented data from the NA ACCORD looking at TGW compared with CIS gendered women and CIS gendered men. Although there were only 123 TGW compared with 6979 CW and 35751 CM; TGW spent 0.7more yrs.  and 0.2 more yrs. virally suppressed than CW and CM (and the differences were smaller after adjustment). The authors conclude that TGW who engage in care have similar outcomes to other groups. Noted should be the very small numbers and that there may be many more TG persons who don’t engage in care compared to CW and CM.

There was a covid 19 lunch session, which I reckon had to have been one of the most popular picks. There were some great overviews and temporal examination of the spread of the infection (Dr Wu (I think) china CDC). Also, some useful data regarding the risks. We all know the most common symptoms are fever, dry cough and fatigue. Outcomes are worse in people with HT, DM, CVS disease and lung disease. Severity and spread are so widespread as this is a new infection, there is no treatment and limited control and it is highly contagious. Most of the initial spread in china was within family clusters and close contacts – schools and other close settings was not a main driver in china. In china 1.4 BILLION people were in home isolation for 10 days (no wonder there was no manufacturing!) and in Hubei 59.2 million people are within the cordon. Of people infected 40% have mild infection, 40% have mild infection + pneumonia, 15% are severe and 5 % critical. The time between exposure and symptoms is typically 5-6 days, and from symptoms to recovery 2-6 weeks. Time from symptoms to death is usually 2-8 weeks (not a lot of time to do that final bungee jump or skydive). Kids have milder infection than adults, and its believed that virus shedding is highest early in infection however can last 7-12 days in mild infection and >2 weeks in severe infection.  Brooks (CDC) covered the basics and the added tat incubation was average 4-6 days although could be from 2-14 days. The fatality rate was 0.5%-3.5% (influenza fatality rate 0.1%). Covid-19 was detectable in respiratory secretions and stool, no MTCT had been reported and the effect in HIV positive individuals was thought to be related to level of immunosuppression (VL and CD4 cell count).in pregnant women, morbidity was thought to be equivalent to non-pregnant women. 
There was also discussion of treatment which included remdesivir (nucleotide analogue); kaletra + interferon; broad spectrum antibiotics; chloroquine and monoclonal antibodies. 

At this stage, I think I started to feel fatigue and maybe a dry cough?? Anyway, that’s it for now.