STIs and HIV 2008

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This presentation was given by Andrew Grulich at the 2008 AFAO HIV Educators conference.

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STIs and HIV 2008

  1. 1. Trends in STIs and HIV in MSM in Australia Overview of the Swiss consensus statement Professor Andrew Grulich National Centre in HIV Epidemiology and Clinical Research, UNSW, Sydney
  2. 2. Outline <ul><li>STIs </li></ul><ul><ul><li>Routine surveillance </li></ul></ul><ul><ul><ul><li>Recent developments </li></ul></ul></ul><ul><ul><li>Enhanced surveillance </li></ul></ul><ul><ul><li>Research findings </li></ul></ul><ul><li>The “Swiss consensus statement” </li></ul>
  3. 3. Routine STI case surveillance <ul><li>Until very recently, no data on sexuality has been collected </li></ul><ul><li>Alternate imperfect approaches </li></ul><ul><ul><li>STI rates in men aged 30-49 </li></ul></ul><ul><ul><ul><li>low rates in heterosexual of this age </li></ul></ul></ul><ul><ul><li>STI rates in urban men </li></ul></ul><ul><ul><ul><li>because of high STI rates indigenous people </li></ul></ul></ul>
  4. 4. Chlamydia in men aged 30-49 years by year and state/territory
  5. 5. Gonorrhoea in urban men by year and State/Territory
  6. 6. Gonorrhoea in men aged 30-49 years by year and State/Territory
  7. 7. Infectious syphilis in men by year and State/Territory
  8. 8. Syphilis enhanced surveillance data, NSW <ul><li>Significant further increase in 2007 </li></ul><ul><li>In South-Eastern and Central Sydney </li></ul><ul><li>Around 95% in men, almost all MSM </li></ul><ul><li>Around 50-60% of cases continue to be in HIV positive men </li></ul><ul><li>Around 15% of cases are relapse/re-infection </li></ul>
  9. 9. Syphilis sentinel surveillance, Victoria Victorian Primary Care Network for Sentinel Surveillance on BBVs and STIs* Syphilis Report 1: April – December 2006
  10. 10. From 2007/08 <ul><li>National agreement to report data on </li></ul><ul><ul><li>sexuality for </li></ul></ul><ul><ul><ul><li>infectious syphilis </li></ul></ul></ul><ul><ul><ul><li>gonorrhoea </li></ul></ul></ul><ul><ul><li>site (anus/throat/urethra) for gonorrhoea </li></ul></ul><ul><ul><li>(probably) some data in NCHECR ASR 2008 </li></ul></ul><ul><li>ACCESS </li></ul><ul><ul><li>A sentinel surveillance system for chlamydia which will report data on sexuality from 2008/09 </li></ul></ul><ul><ul><ul><li>Also a component on genital warts from 2009 </li></ul></ul></ul>
  11. 11. Research data from pH and HIM Jin et al, STI 2007
  12. 12. Summary <ul><li>Rates of chlamydia, gonorrhoea, and syphilis are increasing </li></ul><ul><li>This is occurring in every state, with little variation (except syphilis) </li></ul><ul><li>Co-incident with increases in sexual risk behaviour </li></ul><ul><ul><li>Gonorrhoea: increases started from low rates in mid 1990’s </li></ul></ul><ul><ul><li>Chlamydia: since the start of surveillance in the mid 1990’s </li></ul></ul><ul><ul><li>Syphilis: started in Sydney around 2000, now spreading around Australian capitals </li></ul></ul>
  13. 14. Trends in HIV prevalence Sample is men aged 30-49 recruited at non-clinic sites. Declining HIV seroprevalence gay men aged < 50 in Sydney
  14. 15. Summary <ul><li>STIs on the increase everywhere </li></ul><ul><li>HIV </li></ul><ul><ul><li>Increasing in MSM in most locations </li></ul></ul><ul><ul><ul><li>NSW is an exception: ten years of stability </li></ul></ul></ul><ul><ul><li>Increasing in heterosexuals in WA </li></ul></ul><ul><li>Why the difference between HIV and STIs? </li></ul><ul><ul><li>See Sexual Health special edition, June 2008 </li></ul></ul>
  15. 16. The Swiss statement: what happened? <ul><li>In January 2008 (while we were all lying on the beach) </li></ul><ul><li>A statement was published in the Bulletin des Medicins Suisses (which we all read weekly!) </li></ul><ul><li>In French (in which we are all fluent) </li></ul><ul><li>By From 4 Swiss HIV Clinicians </li></ul><ul><ul><li>On behalf of the Swiss National AIDS Commission </li></ul></ul><ul><li>Out of the blue came the “The Swiss Consensus Statement”, which at face value said </li></ul><ul><ul><li>“ people with undetectable viral load are sexually non-infectious” </li></ul></ul>
  16. 22. What does the statement say? <ul><li>An HIV infected individual who is on effective ART with completely suppressed viraemia is sexually non-infectious, as long as </li></ul><ul><ul><li>The individual is compliant with therapy and evaluated regularly by a physician </li></ul></ul><ul><ul><li>Viral load has been undetectable for at least 6 months </li></ul></ul><ul><ul><li>No additional STDs are present </li></ul></ul><ul><ul><li>(not stated but implied: heterosexual) </li></ul></ul>
  17. 23. The data from Ugandan heterosexuals Quinn T et al. NEJM 2000 342, 921-929.
  18. 24. Limitations of the available data <ul><li>Untreated individuals </li></ul><ul><ul><li>Results do not necessarily apply in treated individuals </li></ul></ul><ul><ul><li>All ARV’s do not penetrate semen equally </li></ul></ul><ul><ul><ul><li>There is a correlation, but not a perfect one, between serum and semen viral load in treated individuals </li></ul></ul></ul><ul><li>Only 50 couples in undetectable category </li></ul><ul><ul><ul><li>A low rate of transmission would have easily been missed </li></ul></ul></ul><ul><li>There have been 0 sufficiently powered cohort studies of HIV transmission from people on ARV therapy </li></ul><ul><li>No data on homosexual men (infectiousness 10-30 fold higher) </li></ul>
  19. 25. Summary <ul><li>The Swiss statement does not </li></ul><ul><ul><li>Provide data from a new study </li></ul></ul><ul><ul><li>Provide a systematic review of available evidence </li></ul></ul><ul><li>It is the “expert opinion” of 4 HIV clinicians </li></ul><ul><ul><li>On generally accepted scales, “expert opinion” is the lowest form of scientific evidence </li></ul></ul><ul><ul><li>Very open to bias </li></ul></ul><ul><li>The response to the statement does highlight that our knowledge in this area is incomplete </li></ul><ul><ul><li>Should we do a study of HIV transmission and viral load in serodiscordant couples? </li></ul></ul>
  20. 26. ..so what is the state of the science? <ul><li>It is very likely that lower serum viral loads are associated with reduced risk of HIV transmission </li></ul><ul><li>The question is “how much lower?” </li></ul><ul><li>It is quite possible that the effectiveness of relying on undetectable viral load is substantially less that the effectiveness of using condoms </li></ul><ul><li>Where might a reliance on undetectable VL fit into our rapidly expanding collection of “risk reduction behaviours” ? </li></ul>

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