Marjo Taal & Hanna Bos 26 juli 2018

Transcription

1 Marjo Taal & Hanna Bos 26 juli 2018

2 Synergie in de soa-bestrijding Wat gaat er goed in de NL soabestrijding en waar ben jij trots op?

3 Syndemics.. synergie! ons_stis/video/video_sti_s.std?ext=.mp4

4 Programma 1. Start-up 2. Syfilis 3. Soa en PrEP? 4. Soa kliniek in the future

5 Synergie Disease Concentration Disease interaction Large scale social forces

6 Gonorrhea in the U.S

7 HIV and STI Synergy Inflammation and/or ulceration STI BEHAVIOR Condomless sex Multiple partners PrEP and TasP HIV transmission and/or acquisition Higher risk partners, risk of HIV-infected partner

8 HIV and STI Synergy Inflammation and/or ulceration STI BEHAVIOR Condomless sex Multiple partners PrEP and TasP HIV transmission and/or acquisition Higher risk partners, risk of HIV-infected partner

9 it s the mucosa/microbioom! DGI: gedissimineerde gonorroe go vaccin & China MSM migrants: prioriteit PrEP HCV eliminatie: gedragsverandering!

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11 Syfilis

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14 Congenital Syphilis Cases by Year of Birth and rates of Primary and Secondary Syphilis among Women, United States, Source: Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention

15 Decline in the number of penicillin API manufacturers over the past decade, Pre Pre-1995 Current CSPC China NCPC China Jiangxi Dongfeng China Sandoz Germany Closed plant Wyeth India King USA Pfizer USA Alembic India Bristol Europe UK Aventis France GIST Brocades Netherlands Acquired by DSM* Acquired by Pfizer Acquired by Pfizer Ended production Ended production Ended production Ended production Source: Melanie Taylor, RHR/STI, WHO Geneva.

16 A Vicious Cycle: STDs predict future HIV Risk Rectal GC or CT Primary or Secondary Syphilis No rectal STD or syphilis infection 1 in 15 MSM were diagnosed with HIV within 1 year.* 1 in 18 MSM were diagnosed with HIV within 1 year.** 1 in 53 MSM were diagnosed with HIV within 1 year.* *STD Clinic Patients, New York City. Pathela, CID 2013:57; **Matched STD/HIV Surveillance Data, New York City. Pathela, CID 2015:61

17 Syfilis Toepassing in jouw werk? Vragen aan experts? Vragen aan andere disciplines?

18 PrEP en soa

19 Risk Compensation adjustment of behaviour in response to a perceived reduction in risk. Critical issue in the public health implementation of biomedical interventions: Could increased risky sexual behavior counteract the biological efficacy against HIV? Behavioral adaptation: Behavioral changes triggered by a safety measure: reduction in condom use Behavioral disinhibition: Lack of restraint with more risk taking behaviors: increasing nr of partners, nr of sexual acts, chemsex STIs: Best objective measure of risk compensation and most feared consequence of risk compensation Individual vs. population impact of biomedical interventions: risk compensation among people not using PrEP/TASP Risk management plan: Assess the public health impact of PrEP Cassell BMJ 2006

20 Figure 10 New diagnoses of HIV and STIs from 1996 to 2015 in MSM in England Unemo M et al. Lancet Infect Dis 2017

21 Unemo M et al. Lancet Infect Dis 2017

22 Community-Level Changes Figure in 11 Condom use with Casual Partners Among MSM 30% 1% 46% The Lancet Infectious Diseases , e235-e279doi: ( /S (17) ) Copyright Holt M. et al. Lancet HIV 2018

23 Meta-analyis of effect of PrEP on STIs diagnosis among MSM Significant increase in any rectal STI diagnosis (OR: 1.39, 95% CI: ) Significant increase in rectal chlamydia (OR: 1.59, 95% CI: ) Increase in STIs rates in more recent studies (OR: 1.47, 95% CI: ) Traeger MW et al. CID 2018

24 Partners, not condom use drive STIs rates Golub S et al. CROI 2018 Boston SPARK: Community-based PrEP demonstration project in NYC 261 MSM followed until M12 after PrEP intitiation Decrease in condom use: 61% to 46% Predicting Factors of STIs aor 95% CI p Age < 25 years old < 0.05 > 5 casual partners at BL < 0.01 STIs in 6 months pre-prep <0.05 Increase in Nb casual partners < 0.05 Neither overall condom use nor change in condom use were associated with STIs diagnosis in the 12 months following PrEP uptake

25 PrEP en soa Toepassing in jouw werk? Vragen aan experts? Vragen aan andere disciplines?

26 STI clinic in the future Dean Street Express, London

27 Time to treatment Pre Express Post Express Time attendance to informed of result (hours) Time attendance to treatment (hours) Byrne et al, BASHH oral presentation 2015 Whitlock et al, Int J STD&AIDS 2018

28 CT/GC in HIV negative MSM Tests Tests Chlamydia any site Chlamydia diagnoses Chlamydia tests Gonorrhoea any site Gonorrhoea 2013 diagnoses Gonorrhoea 2016 tests 2017 HIV and STI test and diagnosis trends in MSM attending Dean Street Clinic, 2012 to 2016 (GUMCAD) Diagnoses Diagnoses

29 STI models of care Private Pro s High coverage Can easily provide basic STI screening services Contra s Most patients not at high risk STIs not a priority Lack of expertise Public Health Impact Generalized epidemics Public Pro s Serve high-risk populations Diagnose and treat large numbers of STIs High level of expertise Contra s Low coverage Stigma Public Health Impact Concentrated epidemics

30 Concentrated Epidemics HIV Syphilis Gonorrhea LGV Hepatitis C Most of these infections are overlapping epidemics among populations that STD clinics have access to: MSM Sex workers injection drug users other high-risk populations

31 Online services: SH24 Mobile friendly and online

32 Digital vending machine BioSURE HIV self-tests: 3 rd generation Wall mounted at eye level Touch screen Robust - liquid proof secure (>300 machines, no incidents) Lifespan hundreds of thousands of vends Little maintenance, can be done remotely Access website for live monitoring of sales, issues and epidemiological data Installed Brighton Sauna June 2017

33 GPS to predict the next event You probably met gonorroea at.. Your nearest STI care that is open now is.

34 STI clinic in the future Social media campaigns Tailored risk reduction advice online Links to community organisations Branded services tailored to diverse needs Outreach in hot spots and/or to support local community needs Wellbeing programme Self-sampling Self-testing

35 Barriers Funding constraints a small pot for prevention complacency amongst policy-makers/funders/ Provider constraints slow to adopt new technologies, resistant to change, paternalistic not knowing/connecting with users negative attitudes persist Population constraints fear and stigma have not gone away

36 Solutions Funding constraints tackle the cost of tests a global issue make throughput efficient for lab (upscale) and clinic (differentiate) Provider constraints top-down, bottom-up create the team that gets the technology keep it lively refresh campaigns, start new ones, reward staff, trust the users Population constraints work with community champions on positive messages be inclusive, celebrate diversity

37 STI clinic in the future Toepassing in jouw werk? Vragen aan experts? Vragen aan andere disciplines?