Treatment Trends for South African MSM Kevin Rebe
Why MSM? MSM are at high risk of HIV transmission and acquisition Identified in current NSP for targeted health services South Africa = 10.4 to 44.5% Increased HIV risk compared to general population (OR 3.8 in Africa) Baral S et al. PLOS Medicine 2007 Dec. (4)12 Rates in MSM always higher than heterosexual men Stigma and discrimination, many barriers to healthcare access NEW MODELING DATA: Providing targeted programs for MARPS benefits a countries overall HIV response and decreases overall HIV rates (Beyrer et al MSMGF Conference Vienna 2010)
Interface of MSM and hetero epidemic 50% of Soweto MSM had sex with women too Need to treat concentrated key population epidemics to positively impact on country wide epidemic
High biological risk of HIV transmission from anal sex? Vagina Anus Adapted for sex Thick mucosal surface Self lubricating before sex Not adapted for sex Thin mucosal surface Not self lubricating Mucosal tears HIV entry-point
Challenges to Overcome Country buy-in and support Policy makers and law makers Community buy-in / advocacy Health Model vs Disease Model Police, schools, healthcare centres Funding Frame MSM-targeted health care Enabling around clinical holistic spaces health services Sensitivity and competency skills for staff Stand-alone Not ideal to versus attract fully MSM integrated into services? Culturally care when appropriate disease already IEC and exists related prevention materials Management algorithms MSM targeted and appropriate Responsive to local disease burdens Align with existing country guidance, funding, resources etc but should not follow heteronormative models
MSM Services Identified by WHO HIV screening and treatment (CD4 <350 cells/mm 3 ) Management of HIV related illness Appropriate counseling and support Prophylaxis IPT / Fungal / Co-trimaxazole STI prevention, screening and treatment Malaria prevention Vaccination e.g. hepatitis B, pneumococcal, flu (Integrated TB services) South Africa
HIV Treatment For MSM MSM-appropriate HIV screening CD4 monitoring pre-art (VL monitoring on ART?) ARV Treatment According to in-country guidelines (equivalent to that available to heteroexual men and women) NRTIs, NNRTIs and PIs to construct robust 1 st and 2 nd line regimens Adherence High mental health disease burden Different support structures especially in stigmatised / crimilalised settings Recreational substance and alcohol use Special circumstances Pharmaceutical marketing to gay-identified MSM Body conscious culture Drug interactions e.g. anabolic steroids, recreational chemicals, hormones for TG Side effects such as erectile dysfunction Earlier treatment for prevention given high transmisibility of HIV during unprotected anal sex
HIV Treatment For MSM Appropriate HCT Sensitivity from counselor Able to take a sexual history Understands normal range of sexual behaviours including anal sex Able to identify risks of HIV transmission Able to council about risk reduction
HIV Treatment For MSM ARVs according to DOH guidelines as for heterosexual men and women When to start? CD4 count < 350 cells/mm 3 Any WHO stage 4 defining illness Any patient with TB (sensitive and MDR/XDR) [For prevention of HIV transmission / TasP]
Fixed Dose Combination Tenofovir + emtricitabine + efavirenz Fixed Dose Combination (FDC) Low pill burden adherence Convenient Currently limited stock Phased implementation Beware stock outs!
Challenges in HIV Treatment for MSM Hepatitis B or C co-infection More common in MSM Worse outcomes if co-infected LFT derangment Drug induced hepatitis Rapid development of cirrhosis Lack of hepatitis B vaccine programs Lack of hepatitis C vaccine! Limited treatment access Very expensive Low cure rates Terrible side effects Only available in some tertiary centres Prevention is better than cure!
HIV Summary MSM are at high risk for HIV Attracting MSM to healthcare is difficult Appropriate messaging and services Use STIs as a hook Treatment in South Africa is the same as for heterosexuals Early treatment of highest risk groups Condoms and lube Consider Mental health and substance use
STI s are a hook MSM presenting with an STI Provide additional services Risk assessment for HIV HIV testing and linkage to care Screen for alcohol and substance use Screen for mental health problems Build clinical relationships
Assess and Treat STIs STIs may increase HIV disease burden Disrupt mucosal barriers Cause sub-endothelial inflammation Increase viral load Marker for risky sexual behaviours
STIs: A Little Anatomy Pharyngeal Receptive oral sex Rimming Urethral Penetrative oral sex Penetrative anal sex Anal Receptive anal sex?rimming?sex toys
STI Screening is Difficult Syphilis serology Hard to differentiate incident from prevalent disease in the face of potential repeat exposures Some rapid test disappointing in clinical settings GC are intracellular so Screening need is CELLS NOT routinely lab done in state clinics submitted specimens for culture. Culture may be insensitive Empiric treatment CT cannot be routinely cultured. Serology may be insensitive
Nucleic Acid Amplification Sensitivity of the APTIMA COMBO 2 Assay has been shown to be superior to culture, serology and direct specimen tests Not validated for pharyngeal or anal specimens although outperforms classical investigations in many studies to date
Asymptomatic STIs Syphilis Hepatitis and other sexual viruses HIV Gonorrhoea (GC) Chlamydial infection (CT) Majority of non-urethral GC and CT are likely to be asymptomatic
Recommended Screening for ASTIs CDC (and various USA & EU guidelines) Yearly syphilis PCR screening of pharynx, anus and urethra based on sexual history WHO: Presumptive STI treatment for at risk MSM Reported UAI in the last year PLUS Partner with an STI OR Multiple partners
The ASTI Study at Health4men Symptomatic and Asymptomatic STI Screening among MSM. Rebe, K, Lewis D, Myer L, Struthers, H, McIntyre JA Funding from USAID/PEFAR via Anova Health Inst. Prospective study, convenience sample 200 MSM recruited between Jan-Jul 2012 Socio-behavioral and symptom questionnaire Detailed clinical examination for STIs HIV, syphilis screening PCR for GC and CT at 3 anatomical sites Validation of an in-house PCR kit
Results Raw, uncleaned data All percentages are approximate only Indicator No Percentage Total MSM participants 200 100 Transgender 15 7.5 History of transactional sex 77 38.5 HIV positive 88 44% New HIV diagnoses 8 4% New syphilis diagnoses 18 9% Total PCR + for GC or CT 63 (31%) Symptomatic PCR + 15 Asymptomatic PCR + 48 (24%) Rebe K et al, Unpublished
Both MDR isolates were collected from MSM Health4men response: MDR-GC Enhanced case management MSM surveillance
Enhanced Case Management of MSM Assess and treat as per country guidance Cefixime 400mg PO stat Doxycycline 100mg 12hrly for one week HIV and syphilis screening with Urethritis Additional management: Sexual behavior questionnaire Urethral swab sent for culture and sensitivity estimation Contact tracing and call back if resistance identified Treatment failures retreated with 500mg IMI ceftriaxone
Results Approx 30 MSM screened 1 MDR gonoccocal isolate identified Not sexually networked with JHB cases Isolate is identical to JHB cases More than one inoculation into SA MSM community Successfully treated with IMI ceftriaxone All (three) sexual contacts traced and treated
Implications Current South African STI Guidelines are inadequate: Fail to diagnose and treat nonurethral gonorrhoea Fail to monitor for resistance rates Fail to diagnose asymptomatic gonorrhoea among MSM
PrEP in Africa PrEP knowledge generally low among African MSM Increased in Cape Town by iprex recruitment Acceptability studies suggest MSM would use the intervention (Eisingerich et al)
PrEP Implementation Pipeline Adequate evidence base Clinical guidance Demonstration projects Drug licensing (FDA and Local) Safety monitoring Government buy-in Funding commitment Community education PrEP IEC materials Training of HCW Supply chain logistics Create advocacy and demand Re-evaluate and Refine Implement Adherence Support
Is Medical Male Circumcision Effective Overall probably no! for MSM? Some people might benefit Men who are exclusively penetrative Bisexual men Obviously MMC wont prevent anally acquired HIV Will protect men who are at risk for vaginal acquisition of HIV but sometimes also have sex with men Acceptability for gay-identified MSM?
Anal Health, AIN and Cancer Anal HPV is very common and increases cancer risk Anal examination is usually not done for MSM attending heteronormative HIV services AIN is a cancer precursor NO SCREENING NO REFERRAL NO HPV VACCINATION
HIV Positive MSM Cured 14 patients functionally cured 10 men and 4 women Started ART immediately at seroconversion Remained on treatment for an average of 3 years Stopped treatment for average of 7 years and viral load remains LDL Implications are not yet clear DO NOT stop ART based on this study!
MSM Health Care in SA 6000 Ivan Toms Centre for Men s Health Cohort Size 5000 4000 3000 2000 1000 0 Q1 2009 Q2 2009 Q32009 Q42009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Patient numbers
Contact: rebe@anovahealth.co.za info@health4men.co.za Tel: 021 447 2844