Australasian Society for HIV Medicine

The 2007 conference was held on the Gold Coast from 8-10 October The inaugural Gollow Lecture was given by Ron Jones (University of Auckland). He presented an overview of the history of cervical and lower genital tract malignancies, and paid tribute to six eminent Australian researchers who helped revolutionise the diagnosis of these conditions.

There was an excellent Symposium on HIV and Women. David Lewis (National Institute of Communicable Diseases, South Africa) gave an overview of the epidemic in his adopted country. Eighty-seven percent of the world's HIV-infected children (under 15 years old) reside in sub-Saharan Africa. Apart from the numbers, he stressed the ongoing problems of violence against women as fuelling the epidemic and thwarting prevention efforts. Nevirapine resistance is cited as an emerging problem in the prevention of mother-to-child transmission and is increasing because of the lack of alternative drug regimens. Jayne Russell (Latrobe University) presented the preliminary findings from her PhD which involved 15 structured interviews with infected women and their doctors around the role of community based organisations for psychosocial support. Referral patterns are influenced by single experiences clinicians have with community-based organisations or personal interactions with infected women who belong to such organisations. In contrast to men, infected women are less knowledgeable about HIV/AIDS and experienced considerable social isolation as a result of stigma. Finally, Virginia Furner (Albion Street Centre) gave an overview of the epidemic in the developing world, with reference to issues around mother-to-child transmission and (un)availability of ART.

There was a comprehensive plenary regarding the role of syndromic management of STIs in the developing world given by David Lewis (South Africa) and Ron Ballard (CDC, Atlanta). The key points made were to emphasise that international guidelines, such as those issued by WHO, should be tailored to suit the local context. In addition, there is a need for supplementary, cheap and rapid diagnostic tests to enable accurate treatment and revision of algorithms and for the purposes of sentinel STI surveillance. The "elimination" of chancroid from the South African mines was cited as an example of the success of syndromic management of genital ulcer disease; whereas the treatment of syphilis in some communities outside Johannesburg was often delayed because of the scarcity of appropriate antibiotic supplies.

Perhaps the most interesting work presented at this conference was a panel presentation exploring the reason(s) for the increase in HIV infections in NSW, VIC and QLD. Rebecca Guy compared the incidence rates for the three states. In VIC, the incidence rate had increased from 2.9 per 100,000 people in 1998 to 5.6 in 2006. In NSW the incidence rate is stabilising (5.9 infections per 100,000 people). Jeffrey Grierson talked about the increase in STI/HIV testing amongst MSM given the synergy between the two infections; but he stressed that increased screening was not the only reason for increases in HIV incidence. In NSW, for example, the institution of the STIGMA guidelines has seen more frequent screening of gay men, but the HIV incidence rate is stabilising. John Imrie talked about the role of "serosorting" and sexual behaviours based on information from several of the state-based period surveys. Garret Prestage and Matthew Law presented an interesting model which took into account the Census data from the Australian Bureau of Statistics as well as HIV epidemiology data. They estimated that HIV prevalence was highest in NSW, followed by VIC and QLD, and discussed some of the statistical reasons for the differences observed between the states. Finally Andrew Grulich gave an overview of HIV incidence in the developed world. Of the countries assessed, HIV incidence had increased in all countries except Greece (the reason was unknown). In the UK, for example, HIV incidence has probably increased in part due to the increase in HIV testing, particularly in genitourinary clinics, but in other countries, such as the US, there had been documented increases in unprotected anal intercourse driving the numbers. The session ended with a panel discussion, which recommended that in the Australian context, research into why men are having more unprotected anal intercourse is needed and that the introduction of the de-tuned HIV antibody test (which will detect early seroconverters) may assist in our understanding of a changing epidemic. Late presenters, the role of community-based organisations, the effect of inter-state migration and the potential "de-centralisation" of the epidemic from NSW were also discussed. The information in this symposium will be presented in more depth in a special edition of Sexual Health in early 2008.
Report by Derek Chan
Division of Sexual Health
Albion Street Centre, Surry Hills NSW 2010

Further reports on sessions at the Conference

The last day of the Australasian Sexual Health Conference concluded on a high note with two excellent plenaries. The first was titled "Testing, Testing, Testing". Ron Ballard from the Centers for Disease Control and Prevention, USA, gave an inspiring talk on point of care (POC) tests. This followed on from the day 1 plenary on STIs in developing countries that demonstrated the very high rates of STIs in some developing countries, the wide spread use of syndromic management and the limitation of syndromic management for STIs with mild or no symptoms. Syphilis is frequently asymptomatic and although RPR tests can be done at the POC, its use in non experienced hands produces less than ideal results. The currently available POC tests are all specific or treponemal tests. This means that they generally remain positive for life, even after treatment. Dr Ballard showed that although the POC treponemal test was vastly more sensitive than RPR done at the POC for screening pregnant women, many women would be unnecessarily retreated with only a POC treponemal test in use. The ideal POC test for syphilis is one that combines both a treponemal and non treponemal test. Such a test is being developed under the name "signal spirolipin treponemal test". It is currently a five step test but the aim is to reduce it to two steps. The reader has a triangular in which three dots may appear. One dot is the control, the second becomes positive if the treponemal test is positive and a third is a non treponemal test. Three dots means treatment for syphilis is required.

A rapid test for Chlamydia trachomatis infections is another much needed development. The Cambridge Chlamydia rapid test is a POC test that has about 80% sensitivity and 98% specificity when compared to PCR. In field use the lower sensitivity of the PCR is offset by the fact that the results are available in 40 minutes, so the client gets treated on the day of testing. More clients are treated with the POC test because of the loss of specimens in transit and failure of clients to return with a sent away PCR test. The most exciting POC concept discussed had the elusive name "backscatter interferometry". This is a test technology that measures changes in refraction of a laser light with changes in the size of molecules. It is able to give quantitative results, which are available in seconds using a small desktop reader and a common laser light. It has potential applications for quantitative detection of antibody such as RPR testing, detection of antigen with the use of a capture antibody, nucleic acid detection similar to a real time PCR and semi quantitative measurements of HIV viral load. It is certainly an exciting area of development.

Professor Suzanne Garland gave a comprehensive overview of testing in pregnancy for infectious diseases. The Royal Australian and New Zealand College of Obstetrics and Gynaecology recommends universal antenatal screening tests on the basis that selective screening is unreliable, that the tests should be offered at preconception or first antenatal visit, and that informed consent for the tests should be obtained. STI testing is recommended for HIV, Hep BsAg, Syphilis; hepatitis C and Chlamydia testing is recommended in the under 25 year old antenatal population. Other recommended tests include rubella, varicella zoster, group B streptococcus and asymptomatic bacteruria. She recommended the ASID guidelines which are available on the RACP website for those requiring management information.

Associate Professor Sepehr Tabrizi spoke on Laboratory Contribution for Control of Chlamydia. He reassured us about the Chlamydia trachomatis variant that has been noted to be present in Sweden, which was not detected on the Abbott PCR test in use at the time. This variant was detected when a sudden drop in Chlamydia notifications was noted in specific geographic areas of Sweden. The variant accounted for 25% of new Chlamydia cases at that time. The variants were all serotype E and it was postulated that the use of a test that didn't detect that variant drove the development of the mutant species. However, the variant was only detected in a few cases in neighbouring countries, Norway and Denmark, and was not detected in 1000 samples tested in Australia. The new Abbott test that detects the variant is now in use in Sweden, and this particular variant seems to have been successfully managed. Another variant of Chlamydia trachomatis LGV serotype, L2b has been detected in the UK that was not detected on Roche PCR. This variant seems not to transmit, so will only occur in sporadic cases. A/Prof Tabrizi concluded with a discussion on Chlamydia genotyping in its investigative role of types present in the population. The predominant serotype among MSM is Australia has been shown to be D, whereas E is the predominant serotype among women. Rectal swabs from Sydney compared to other areas had more diversity of genotypes found. Genotyping will continue to provide insights into the epidemiology of Chlamydia infections.

The closing plenary had two dynamic speakers talk on two very different area of prevention. Angela Williams from the Victorian Institute of Forensic Medicine showed her obvious dedication to the subject of her talk by travelling from Melbourne with a two week old baby. Dr Williams's presentation was titled "Is Sexual Assault Preventable?" and was about a program developed by herself and others to address the issue of sexual assault in the broader community. Recent high profile incidents of sexual assault by AFL players prompted the education package to be given to AFL clubs, both to address the specific needs of elite sportspeople and also as a top down approach to reach the broader community. Dr Williams talked us through the delivery of the education package and the responses of the players. Her key themes were: the role of the individual in showing respect to other people; determining whether or not consent for the sexual activity they are about to undertake with another person has been given by that person; and the role of the bystander in stepping in if they perceived a sexual assault is about to occur. The education packages obviously had a huge impact on the individual players, and the conference audience expressed the belief that such education should be available more widely and to younger boys.

Professor Ron Jones's talk was titled "Is Vulval Cancer Preventable?" and certainly gave members of the audience an insight into the importance of detecting premalignant vulval changes. Although vulval cancer is relatively uncommon, increasing incidences particularly in younger women have been noted in both the UK and USA. Prof Jones described two distinct vulval squamous cell carcinomas. The first is high risk HPV associated, occurs in younger women, is associated with smoking and vulval intraepithelial neoplasia (VIN), usual type. The second type occurs in a background of chronic vulval dermatoses such as lichen sclerosus, in older women and is associated with VIN, differentiated type. Multiple examples of VIN were shown to the audience, and the importance of biopsy of any suspicious vulval lesions was reinforced. Adequate management of vulval symptoms, including early diagnoses of dermatoses and VIN plus vaccination for HPV 16 and 18, has the potential to decrease the incidence of vulval cancer, but it is likely to be some time before a substantial downturn occurs.

The conference then drew to a close with the announcement of the Australasian Sexual Health Conference 2008, "Diamonds and Pearls" to be held 15-17 September 2008 back-to-back with ASHM at the Perth Convention Centre, Western Australia.
Report by Natalie Edmiston
Pacific Clinic
Newcastle Sexual Health Service

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