Facing the unthinkable: Life-threatening illness in the analyst and its impact on the analytic couple

This article explores the impact of the analyst's life-threatening illness on the analytic couple; it is informed through two theoretical lenses - Freud's ideas about the vicissitudes of mourning, which have been elaborated on by Melanie Klein and John Steiner, and Christopher Bollas's ideas about destiny and idiom. Clinical material will focus on my on-going work with a middle-aged man who has a history of early abandonment and loss and who struggles with being able to remain separate from his objects while being in relationship with them.

In-hospital extracorporeal cardiopulmonary resuscitation for patients with an out-of-hospital cardiac arrest in a semi-rural setting: An observational study on the implementation of a helicopter emergency medical services pathway

Aim

In this study, we aimed to investigate the efficacy of a helicopter emergency medical service (HEMS) facilitated pathway for in-hospital extracorporeal cardiopulmonary resuscitation (ECPR) for patients with an out of hospital cardiac arrest (OHCA) in a semi-rural setting.

Methods

We retrospectively reviewed all patients with an OHCA attended by a UK HEMS service between 1 January 2018 and 20 September 2021, when a dedicated ECPR pathway was in effect to facilitate transport of eligible patients to the nearest ECLS centre. The primary endpoint was the number of patients meeting ECPR eligibility criteria at three pre-defined time points: at HEMS dispatch, during on-scene evaluation and upon arrival in hospital.

Results

During the study period, 162 patients attended met ECPR pathway dispatch criteria. After on-scene evaluation, 74 patients (45%) had a return of spontaneously circulation before arrival of HEMS, 60 (37%) did not meet eligibility criteria regarding initial rhythm or etiology of the OHCA, and 15 (9%) had deteriorated (mainly into asystole) and were no longer suitable candidates upon arrival of HEMS. Eleven patients were eligible for ECPR and transported to hospital in arrest, and a further two patients were transported for post-ROSC ECLS. Nine patients deteriorated during transport and were no longer suitable ECPR candidates upon arrival. ECLS was successfully initiated in two patients (one intra-arrest, and one post-ROSC).

Conclusion

In-hospital ECPR is of limited value for patients with refractory OHCA in a semi-rural setting, even when a dedicated pathway is in place. Potentially eligible patients often cannot be transported within an appropriate timeframe and/or deteriorate before arrival in hospital.

A scalable cryogenic LED module for selectively illuminating kinetic inductance detector arrays

We present the design and measured performance of a light emitting diode (LED) module for spatially mapping kinetic inductance detector (KID) arrays in the laboratory. Our novel approach uses a multiplexing scheme that only requires seven wires to control 480 red LEDs, and the number of LEDs can be scaled up without adding any additional wires. This multiplexing approach relies on active surface mount components that can operate at cryogenic temperatures down to 10 K. Cryogenic tests in liquid nitrogen and inside our cryostat demonstrate that the multiplexer circuit works at 77 and 10 K, respectively. The LED module presented here is tailored for our millimeter-wave detector modules, but the approach could be adapted for use with other KID-based detector systems.

1005 HEALTH-RELATED QUALITY OF LIFE AND FUTURE RISK OF HEALTH OUTCOMES AMONG OLDER ADULTS LIVING IN AUSTRALIA AND THE UNITED STATES

Introduction

Poor health-related quality of life (HRQoL) is associated with higher morbidity and mortality in patient populations. However, whether HRQoL is associated with health outcomes among community-dwelling older people requires further investigation. This study aimed to examine whether HRQoL predicts cognitive decline, dementia, cardiovascular disease (CVD), and mortality in community-dwelling older people living in Australia and the United States.

Method

A cohort of 19,106 individuals from the ASPirin in Reducing Events in the Elderly (ASPREE) study, aged 65–98 years, initially free of dementia or CVD, and who completed the HRQoL 12-item short form (SF-12, version-2) at baseline (2010–2014), were followed until June 2017. The physical (PCS) and mental component scores (MCS) of SF-12 were generated using standardized norm-based method.

Results

Over a median of 4.7 years, there were 2,412 cognitive declines, 574 dementia, 922 incident CVD events, and 1,052 deaths. Using Cox proportional-hazard regression adjusted for a range of covariates, every 10-unit increase in PCS was associated with a 6% lower risk of cognitive decline, a 14% lower risk of incident CVD, and 17% lower risk of all-cause mortality, but was not associated with incident dementia. In contrast, higher MCS was only associated with a 12% and 15% lower risk of cognitive decline and dementia, respectively. Findings did not differ by sex.

Conclusion

Our study provides some of the first evidence that HRQoL can be used in combination with clinical data to identify the future risks of health outcomes among older individuals living in the community. Our findings support the decision of the Australian Commission on Safety and Quality in Health Care to incorporate the SF-12 into the annual Patient-Reported Outcome Measures (PROMs assessment.

Dentate gyrus and CA3 GABAergic interneurons bidirectionally modulate signatures of internal and external drive to CA1

Specific classes of GABAergic neurons play specific roles in regulating information processing in the brain. In the hippocampus, two major classes, parvalbumin-expressing (PV⁺) and somatostatin-expressing (SST⁺), differentially regulate endogenous firing patterns and target subcellular compartments of principal cells. How these classes regulate the flow of information throughout the hippocampus is poorly understood. We hypothesize that PV⁺ and SST⁺ interneurons in the dentate gyrus (DG) and CA3 differentially modulate CA3 patterns of output, thereby altering the influence of CA3 on CA1. We find that while suppressing either interneuron class increases DG and CA3 output, the effects on CA1 were very different. Suppressing PV⁺ interneurons increases local field potential signatures of coupling from CA3 to CA1 and decreases signatures of coupling from entorhinal cortex to CA1; suppressing SST⁺ interneurons has the opposite effect. Thus, DG and CA3 PV⁺ and SST⁺ interneurons bidirectionally modulate the flow of information through the hippocampal circuit.

Population genomic screening of all young adults in Australia to detect familial hypercholesterolemia: a cost-effectiveness analysis

Background

Heterozygous familial hypercholesterolemia (FH) is a highly-penetrant, autosomal dominant monogenic disorder that causes elevated plasma low-density cholesterol (LDL-C) levels and risk of premature coronary heart disease (CHD). To date, the cost-effectiveness of the emerging strategy of genomic screening of adult populations for FH has not been investigated.

Purpose

To assess the impact and cost-effectiveness of offering population genomic screening to all young adults in Australia to detect heterozygous familial hypercholesterolemia (FH).

Methods

We designed a decision analysis model to compare the current standard of care for heterozygous FH diagnosis in Australia (opportunistic cholesterol screening and genetic cascade testing) with population genomic screening of adults aged 18–40 years to detect pathogenic variants in the LDLR/APOB/PCSK9 genes. The model captured morbidity/mortality due to coronary heart disease (CHD) over a lifetime horizon, from a healthcare perspective. Risk of CHD, treatment effects, prevalence, and healthcare costs were estimated from published studies. Outcomes included quality adjusted life years (QALYs), costs and incremental cost-effectiveness ratio (ICER), discounted 5% annually. Sensitivity analyses were undertaken to explore the impact of key input parameters on the robustness of the model. The model structure was designed to be transferable to countries with different healthcare systems.

Results

Over the lifetime of the population (4,167,768 men; 4,129,961 women), the model estimated a gain of 62,722 years of life lived and 73,959 QALYs due to CHD prevention. Population genomic screening for FH would be cost-effective from a healthcare perspective if the cost per test was ≤AU$300 (∼US$233) which would yield an ICER AU$28,000 cost-saving.

Conclusion

Based on our model, offering population genomic screening to all young adults to detect FH could be cost-effective in the Australian healthcare system, at testing costs that are currently feasible.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This work was supported by the Australian National Heart Foundation and Monash University Faculty of Medicine, Nursing and Health Sciences Results from scenario analysesResults from Monte Carlo simulations

Tolerability of four-drug antiretroviral combination therapy in primary HIV-1 infection

Objectives

Rapid initiation of antiretroviral therapy (ART) is important for individuals with high baseline viral loads, such as in primary HIV‐1 infection (PHI). Four‐drug regimens are sometimes considered; however, data are lacking on tolerability. We aimed to evaluate the tolerability of four‐drug regimens used in the Research in Viral Eradication of HIV‐1 Reservoirs (RIVER) study.

Methods

At enrolment, ART‐naïve adult participants or those newly commenced on ART were initiated or intensified to four‐drug regimens within 4 weeks of PHI. Rapid start was defined as pre‐confirmation or ≤ 7 days of confirmed diagnosis. Primary and secondary outcomes were patient‐reported adherence measured by 7‐day recall and regimen switches between enrolment and randomization, respectively.

Results

Overall, 54 men were included: 72.2% were of white ethnicity, with a median age of 32 years old, 42.6% had a viral load of ≥ 100 000 HIV‐1 RNA copies/mL, and in 92.6% sex with men was the mode of acquisition of HIV‐1. Twenty (37%) started a four‐drug regimen and 34 (63%) were intensified. Rapid ART initiation occurred in 28%, 100% started in ≤ 4 weeks. By weeks 4, 12, and 24, 37.0%, 69.0%, and 94.0% were undetectable (viral load < 50 copies/mL), respectively. Adherence rates of 100% at weeks 4, 12, 22 and 24 were reported in 88.9%, 87.0%, 82.4% and 94.1% of participants, respectively. Five individuals switched to three drugs, four changed their regimen constituents, and two switched post‐randomization.

Conclusions

Overall, four‐drug regimens were well tolerated and had high levels of adherence. Whilst their benefit over three‐drug regimens is lacking, our findings should provide reassurance if a temporarily intensified regimen is clinically indicated to help facilitate treatment.

Helicopter emergency medical service dispatch in older trauma: time to reconsider the trigger?

BACKGROUND

Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system.

METHODS

All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request).

RESULTS

1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69-89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34-39]) compared to immediate dispatch (6 min [5-6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%).

CONCLUSIONS

Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.

An absolute risk-guided approach to cardiovascular risk management within a chest pain clinic: the ARCPAC randomized trial

Background

The majority of patients attending chest pain clinics are found not to have a cardiac cause of their symptoms, but have a high burden of cardiovascular risk factors that may be opportunistically addressed. Absolute risk calculators are recommended to guide risk factor management, although it is uncertain to what extent these calculations may assist with patient engagement in risk factor modification.

Purpose

We sought to determine the usefulness of a proactive, absolute risk-based approach, to guide opportunistic cardiovascular risk factor management within a chest pain clinic.

Methods

This was a prospective, open-label, blinded-endpoint study in 192 enhanced risk (estimated 5-year risk ≥8%, based on Australian Absolute Risk Calculator) patients presenting to a tertiary hospital chest pain clinic. Patients were randomized to best practice usual care, or intervention with development of a proactive cardiovascular risk management strategy framed around a discussion of the individual's absolute risk. Patients found to have a cardiac cause of symptoms were excluded as they constitute a secondary prevention population. Primary outcome was 5-year absolute cardiovascular risk score at minimum 12 months follow up. Secondary outcomes were individual modifiable risk factors (lipid profile, blood pressure, smoking status).

Results

192 people entered the study; 100 in the intervention arm and 92 in usual care. There was no statistical difference between the two groups' baseline sociodemographic and clinical variables. The intervention group showed greater reduction in 5-year absolute risk scores (difference −2.77; p&lt;0.001), and more favourable individual risk factors, although only smoking status and LDL cholesterol reached statistical significance (table).

Conclusion

An absolute risk-guided proactive risk factor management strategy employed opportunistically in a chest pain clinic significantly improves 5-year cardiovascular risk scores.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Tasmanian Community Fund

In Vivo Chimeric Alzheimer's Disease Modeling of Apolipoprotein E4 Toxicity in Human Neurons

Despite its clear impact on Alzheimer's disease (AD) risk, apolipoprotein (apo) E4's contributions to AD etiology remain poorly understood. Progress in answering this and other questions in AD research has been limited by an inability to model human-specific phenotypes in an in vivo environment. Here we transplant human induced pluripotent stem cell (hiPSC)-derived neurons carrying normal apoE3 or pathogenic apoE4 into human apoE3 or apoE4 knockin mouse hippocampi, enabling us to disentangle the effects of apoE4 produced in human neurons and in the brain environment. Using single-nucleus RNA sequencing (snRNA-seq), we identify key transcriptional changes specific to human neuron subtypes in response to endogenous or exogenous apoE4. We also find that Aβ from transplanted human neurons forms plaque-like aggregates, with differences in localization and interaction with microglia depending on the transplant and host apoE genotype. These findings highlight the power of in vivo chimeric disease modeling for studying AD.

Defining a study population using enhanced reporting of Aboriginality and the effects on study outcomes

Introduction

The under-reporting of Aboriginal and Torres Strait Islander people on routinely collected health datasets has important implications for understanding the health of this population. By pooling available information on individuals' Aboriginal or Torres Strait Islander status from probabilistically linked datasets, methods have been developed to adjust for this under-reporting.

Objectives

To explore different algorithms that enhance reporting of Aboriginal status in birth data to define a cohort of Aboriginal women, examine any differences between women recorded as Aboriginal and those assigned enhanced Aboriginal status, and assess the effects of using different reported populations to estimate within-group comparisons for Aboriginal people.

Methods

Three algorithms, with different levels of inclusiveness, were used to establish different study populations all of which aimed to include all singleton babies born to Aboriginal or Torres Strait Islander women residing in New South Wales, Australia between 2010 and 2014 and their mothers. The demographics of the four study populations were described and compared using frequencies and percentages. In order to assess the impact on research outcomes and conclusions of using study populations derived from different algorithms, estimates of the associations between smoking during pregnancy and selected perinatal outcomes were compared using rates and relative risks.

Results

Women included in the study population through enhanced reporting were older, less disadvantaged and more commonly resided in urban areas than those recorded as Aboriginal in the birth data. Although rates of smoking and some perinatal outcomes differed between the different study populations, the relative risks of each outcome comparing smoking and non-smoking Aboriginal mothers were very similar when estimated from each of the study populations.

Conclusions

This work provides evidence that estimates of within-group relative risks are reliable regardless of the assumptions made for establishing the study population through the enhanced reporting of indigenous peoples.

Compromised function of the ESCRT pathway promotes endolysosomal escape of tau seeds and propagation of tau aggregation

Intercellular propagation of protein aggregation is emerging as a key mechanism in the progression of several neurodegenerative diseases, including Alzheimer's disease and frontotemporal dementia (FTD). However, we lack a systematic understanding of the cellular pathways controlling prion-like propagation of aggregation. To uncover such pathways, here we performed CRISPR interference (CRISPRi) screens in a human cell-based model of propagation of tau aggregation monitored by FRET. Our screens uncovered that knockdown of several components of the endosomal sorting complexes required for transport (ESCRT) machinery, including charged multivesicular body protein 6 (CHMP6), or CHMP2A in combination with CHMP2B (whose gene is linked to familial FTD), promote propagation of tau aggregation. We found that knocking down the genes encoding these proteins also causes damage to endolysosomal membranes, consistent with a role for the ESCRT pathway in endolysosomal membrane repair. Leakiness of the endolysosomal compartment significantly enhanced prion-like propagation of tau aggregation, likely by making tau seeds more available to pools of cytoplasmic tau. Together, these findings suggest that endolysosomal escape is a critical step in tau propagation in neurodegenerative diseases.

Knowledge and sexual behaviors of transgender individuals faced with the risk of STI/HIV in Benin

Introduction

The issue of sexually transmitted infections (STIs) and Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) cannot be solved without considering the transgender population. This research aims to describe the knowledge, attitudes and sexual behaviors of transgender individuals faced with the risk of STIs and HIV/AIDS in Benin.

Methods

Transgender individuals were selected by respondent-driven sampling throughout the country in 2017. Included in this analysis were individuals who identified as transgender and adopted its mode of expression, aged 15 years and greater, and who gave their consent to participate.

Results

A total of 308 transgender individuals were surveyed, of which 89.6% were of male gender at birth. The participants had a good level of knowledge in the matter of STI and HIV/AIDS. In fact, 99.9% among them cited at least one symptom of STIs; 95.1% cited the three main methods of transmission of HIV and 54% are aware the risk of sexual transmission of HIV is higher between men. Participants were more than 90% likely to declare a positive attitude to care for persons living with HIV (PLWHIV) or to share the same room with them (93.2%). Concerning sexual behaviors, the average age at the first sexual encounter as a transgender individual was 14 years old. During the last three months, transgender individuals declared three regular male partners on average. The usage of condoms during the last sexual intercourse was reported in 86.6% of cases. Knowledge of the serological status of the sexual partner (31.7%) and the loss of sensation induced by the condom (26.8%) constituted the main reasons of non-usage of condoms.

Conclusions

Although adopting some risky sexual behavior, transgender individuals are a population that is relatively well informed and with favorable attitudes regarding STIs and HIV/AIDS. These factors are significant assets to be considered in the development of programs for STIs and HIV/AIDS control.

Key messages

Transgender individuals good level of knowledge is an asset for STIs/HIV control. Sexual multi-partnership seems to be common despite a good level of knowledge.

P2715Diastolic dysfunction in women with ischemia and no obstructive coronary artery disease: novel insight from left atrial feature tracking

Background

Women with signs and symptoms of ischemia but no obstructive coronary artery disease (INOCA) are at increased risk of developing heart failure with preserved ejection fraction (HFpEF); however, the exact mechanism for HFpEF progression remains to be elucidated. Prior studies have focused specifically on impaired left ventricular diastolic function in INOCA. We hypothesized that extending our evaluation to include the left atrium (LA)– a key constituent of the transmitral pressure gradient and left ventricular filling– would provide additional, novel, pathophysiological insight.

Purpose

To evaluate LA function in women with INOCA using cardiac MRI (CMR).

Methods

We performed retrospective feature tracking analysis of cine images from CMR (Figure 1A), to evaluate LA strain, in 58 INOCA women with normal sinus rhythm (three were excluded due to suboptimal image quality). All strain measurements were performed in duplicate by an experienced investigator blinded to clinical status. We subdivided the cohort by an established threshold of resting left ventricular end diastolic pressure (LVEDP) <12 mmHg vs >12 mmHg, performed invasively within a median of 27 days of the CMR. As illustrated in Figure 1B, LA function was divided into three established phases: (1) reservoir strain, passive expansion of the left atrium from the pulmonary circulation while the mitral valve is closed; (2) conduit strain, passive emptying of the atrium into the ventricle; and (3) booster strain, active emptying of the left atrium following atrial depolarization.

Results

Reservoir strain was higher in the elevated LVEDP group (n=20, 26.1 + 1.3%) vs. not elevated group (n=35, 22.8 + 0.9%, p=0.03; Figure 1C). In contrast, we observed no group difference in conduit strain (16.5 + 1.0 and 16.5 + 0.7, p=0.78, respectively; Figure 1D), resulting in significantly higher atrial booster strain in the elevated LVEDP group (10.0 + 1.1% and 7.0 + 0.6, p<0.01, respectively; Figure 1E).

Conclusions

To our knowledge, this is the first report of LA function in women with INOCA. That reservoir strain was higher in subjects with elevated LVEDP provides important pathophysiologic insight regarding diastolic hemodynamics of the LA. The similar conduit function between groups– despite different LVEDP's– strongly suggests a ventricular contribution to the impaired transmitral pressure gradient. Together, these initial proof-of-concept data support the evaluation of LA function in our quest to better understand heart failure progression in INOCA.

Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study

INTRODUCTION

The growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking.

AIM

To outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study.

METHODS

Person-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken.

ANALYSIS

The index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective.

CONCLUSION

Completion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

Protocol of a two arm randomised, multi-centre, 12-month controlled trial: evaluating the impact of a Cognitive Behavioural Therapy (CBT)-based intervention Supporting UPtake and Adherence to antiretrovirals (SUPA) in adults with HIV

Background

Delay to start antiretroviral therapy (ART) and nonadherence compromise the health and wellbeing of people living with HIV (PLWH), raise the cost of care and increase risk of transmission to sexual partners. To date, interventions to improve adherence to ART have had limited success, perhaps because they have failed to systematically elicit and address both perceptual and practical barriers to adherence. The primary aim of this study is to determine the efficacy of the Supporting UPtake and Adherence (SUPA) intervention.

Methods

This study comprises 2 phases. Phase 1 is an observational cohort study, in which PLWH who are ART naïve and recommended to take ART by their clinician complete a questionnaire assessing their beliefs about ART over 12 months. Phase 2 is a randomised controlled trial (RCT) nested within the observational cohort study to investigate the effectiveness of the SUPA intervention on adherence to ART. PLWH at risk of nonadherence (based on their beliefs about ART) will be recruited and randomised 1:1 to the intervention (SUPA intervention + usual care) and control (usual care) arms. The SUPA intervention involves 4 tailored treatment support sessions delivered by a Research Nurse utilising a collaborative Cognitive Behavioural Therapy (CBT) and Motivational Interviewing (MI) approach. Sessions are tailored to individual needs and preferences based on the individual patient’s perceptions and practical barriers to ART. An animation series and intervention manual have been developed to communicate a rationale for the personal necessity for ART and illustrate concerns and potential solutions. The primary outcome is adherence to ART measured using Medication Event Monitoring System (MEMS). Three hundred seventy-two patients will be sufficient to detect a 15% difference in adherence with 80% power and an alpha of 0.05. Costs will be compared between intervention and control groups. Costs will be combined with the primary outcome in cost-effectiveness analyses. Quality adjusted life-years (QALYs) will also be estimated over the follow-up period and used in the analyses.

Discussion

The findings will enable patients, healthcare providers and policy makers to make informed decisions about the value of the SUPA intervention.

Trial registration

The trial was retrospectively registered 21/02/2014, ISRCTN35514212.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6893-z) contains supplementary material, which is available to authorized users.

Telerehabilitation is non-inferior to usual care following total hip replacement - a randomized controlled non-inferiority trial

OBJECTIVES

Determine if outpatient physiotherapy care via telerehabilitation is as effective as in-person physiotherapy care after total hip replacement.

DESIGN

Randomised, single-blind, controlled, non-inferiority clinical trial.

SETTING

QEII Jubilee Hospital, Brisbane, Australia.

PARTICIPANTS

Seventy patients receiving a total hip replacement entered the study, sixty-nine completed the study.

INTERVENTIONS

The control group (n=35; x¯ age 67; female 60%) received in-person outpatient physiotherapy and a paper-based home exercise programme. The intervention group (n=35; x¯ age 62; female 66%) received remotely delivered telerehabilitation directly into their homes and a technology-based home exercise program using an iPad application.

MAIN OUTCOME MEASURES

The primary outcome was the quality of life subscale of the Hip disability and Osteoarthritis Outcome Score measured at six weeks post-operatively. Secondary outcomes included objective strength and balance outcomes, self-reported function and satisfaction outcomes, and home exercise program compliance.

RESULTS

No between group difference was detected in the Hip disability and Osteoarthritis Outcome Score quality of life subscale at the primary end point of six weeks (P=0.970). Strength, balance and self-reported function showed no between group differences. Overall satisfaction was high across both groups, with the intervention group scoring higher for ease of attending appointments (intervention 95 (10), control 86 (18), mean difference 9 (95% CI 2 to 16), P=0.017. The intervention group were more compliant with their home exercise programme (intervention 86% (20%), control 74% (26%), mean difference 12% (95% CI 1% to 23%), P=0.048).

CONCLUSIONS

Telerehabilitation programmes can be delivered to total hip replacement patients in their own homes, using readily available technology while maintaining high levels of satisfaction. More importantly, telerehabilitation patients appear to achieve non-inferior physical and functional outcomes as those receiving in-person rehabilitation programmes.

TRIAL REGISTRATION

ACTRN12615000824561. (Australian New Zealand Clinical Trials Registry).

Pediatric Atypical Teratoid/Rhabdoid Tumors of the Brain: Identification of Metabolic Subgroups Using In Vivo 1H-MR Spectroscopy

BACKGROUND AND PURPOSE

Atypical teratoid/rhabdoid tumors are rare, aggressive central nervous system tumors that are predominantly encountered in very young children. Our aim was to determine whether in vivo metabolic profiles correlate with molecular features of central nervous system pediatric atypical teratoid/rhabdoid tumors.

MATERIALS AND METHODS

Twenty confirmed patients with atypical teratoid/rhabdoid tumors who underwent MR spectroscopy were included in this study. In vivo metabolite levels of atypical teratoid/rhabdoid tumors were compared with molecular subtypes assessed by achaete-scute homolog 1 expression. Additionally, brain-specific creatine kinase levels were determined in tissue samples.

RESULTS

In vivo creatine concentrations were higher in tumors that demonstrated achaete-scute homolog 1 expression compared with those without achaete-scute homolog 1 expression (3.42 ± 1.1 versus 1.8 ± 0.8 IU, P < .01). Additionally, levels of myo-inositol (mI) (9.0 ± 1.5 versus 4.7 ± 3.6 IU, P < .05) were significantly different, whereas lipids approached significance (44 ± 20 versus 80 ± 30 IU, P = .07) in these 2 cohorts. Higher brain-specific creatine kinase levels were observed in the cohort with achaete-scute homolog 1 expression (P < .05). Pearson correlation analysis showed a significant positive correlation of brain-specific creatine kinase with absolute creatine (P < .05) and myo-inositol (P < .05) concentrations.

CONCLUSIONS

In vivo MR spectroscopy may predict key molecular features of atypical teratoid/rhabdoid tumors at initial diagnosis, leading to timely patient risk stratification and accelerating the development of targeted therapies.

P9 Impact of the relocation of a regional neuroscience service on major trauma patients

Objectives

Evaluating the impact of relocating a regional neuroscience service on major trauma patients.

Design

Retrospective analysis of prospectively collected data from 01/08/2013 to 31/07/2017.

Subjects

Patients≥20 years with a TBI in the 2 years pre-relocation (cohort 1) and 2 years post-relocation (cohort 2).

Methods

Patients were identified using the TARN registry. Comparison of the cohorts for demographics, type of neurosurgical input, site of first presentation and the times to first CT head and operation was conducted using cross-tabulation, percentages and statistical analysis (SPSS).

Results

30% of patients in cohort 1 (112 or 373) were admitted in neurosurgery. This increased to 40% of patients in cohort 2 (181 of 450). There was an increase in admissions for monitoring (70% vs 82%). Patients<60 years had a higher increment in admission (+16 points) than patients≥60 years (+8 points). A strong association was found between the relocation of the neuroscience service and the increase in proportion of patients first transported to the major trauma centre (63% vs 74%; p=0.037). There was a significant decrease in the mean time to operation (3.9 hour vs 2.0 hour; p=0.008) and no significant difference in the mean time to first CT head (1.3 hour vs 1.4 hour; p=0.689).

Conclusions

The relocation of neurosurgery has resulted in a significant increase in admission of patients<60 years with TBI in neurosurgery for monitoring, an increase in the proportion of patients first transported to the MTC and a reduction in the time to operation.

Abstract PD4-04: Role of breast MRI in predicting pathologically negative nodes after neoadjuvant chemotherapy in cN0 patients in the I-SPY2 trial

Background

In clinically node-negative (cN0) breast cancer patients with triple negative (TN) and HER2+ disease and breast pathological complete response (breast pCR), low rates of nodal positivity after neoadjuvant chemotherapy (NAC) have been demonstrated. In these patients, the omission of surgical axillary staging has been proposed. However, this information is not routinely known preoperatively. We aimed to validate the correlation between pathologic breast response and pathologic nodal status, and evaluate the relationship between response of the breast tumor on MRI and pathologic nodal status after NAC in cN0 patients in the I-SPY2 trial.

Methods

We identified all patients with cT1-4 cN0 breast cancer prior to NAC from graduated arms of the I-SPY2 trial, a prospective neoadjuvant chemotherapy trial. Absence of residual disease post-NAC was defined as longest diameter (LD) of 0 mm on MRI. Breast pCR was defined as the absence of invasive tumor in the breast at surgery. Associations between ypN0 and patient, MRI, and tumor characteristics were assessed using chi-square tests and univariate regression.

Results

Of 365 cT1-4 cN0 patients included, 128 had HR+/HER2- tumors (35%), 60 HR+/HER2+ tumors (16%), 34 HR-/HER2+ tumors (9%) and 143 TN tumors (39%). Overall, 283 patients (78%) were ypN0 after NAC and 152 patients (42%) had a breast pCR. ypN0 rate was higher in patients with a breast pCR than those with residual disease (93% vs 66%, p&lt;0.001). Patients with HR-/HER2+ and TN tumors were more likely to be ypN0 (97% and 87% respectively) than patients with HR+/HER2- and HR+/HER2+ disease (66% and 71% respectively, p&lt;0.001). Other characteristics associated with ypN0 were tumor grade (grade I 57%, grade II 66%, grade III 84%; p=0.002), MammaPrint Classification (High Risk 1 68% and High Risk 2 87%; p&lt;0.001) and absence of residual tumor in the breast on MRI (87% vs 72% in patients with evidence of tumor on MRI post-NAC/pre-surgery; p=0.003).

In patients with HR-/HER2+, HR+/HER2+, HR-/HER2+ or TN disease and a breast pCR, ypN0 rate was respectively 82%, 96%, 96% and 97% (table 1). In patients with HR+/HER2-, HR+/HER2+, HR-/HER2+ or TN disease and with no evidence of residual disease in the breast on MRI, rate of ypN0 was 71%, 80%, 94% and 96% respectively.

Conclusion

In cT1-4 cN0 breast cancer patients with HR+/HER2+, HR-/HER2+ and TN tumors and a breast pCR, ypN0 rates after NAC are extremely high. In patients with HR-/HER2+ and TN tumors with no residual breast disease on MRI after NAC and pre-surgery, ypN0 rates are high enough to consider omission of axillary surgery. In patients with HR+ tumors, MRI is unsufficiently predictive for pathological response and can therefore not be used to select ypN0 patients. Research on the prediction of ypN0 in cN+ I-SPY2 patients is ongoing.

Nodal status in patients with pCR and absence of residual disease on MRI Number of positive nodesBreast Cancer Subtype0123AllBreast pCR     HR+/HER2-27(82)2(6)4(12)033(100)HR+/HER2+24(96)01(4)025(100)HR-/HER2+24(96)1(4)0025(100)TN67(97)2(3)0069(100)Absence of residual disease on MRI     HR+/HER2-24(71)7(21)3(9)034(100)HR+/HER2+16(80)3(15)01(5)20(100)HR-/HER2+15(94)1(6)0016(100)TN54(96)2(4)0056(100)

Citation Format: van der Noordaa ME, Esserman L, Yau C, Mukhtar R, Price E, Hylton N, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, van 't Veer L, Hirst G, Lancaster R, Wallace A, Alvaredo M, Symmans F, Asare S, Boughey JC, I-SPY2 Consortium. Role of breast MRI in predicting pathologically negative nodes after neoadjuvant chemotherapy in cN0 patients in the I-SPY2 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-04.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p&lt;0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p &lt;0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p&lt;0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-07-03.

Abstract PD4-03: MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL

Background: Detecting residual disease accurately using MRI after NAC to identify both responders and non-responders is essential for de-escalating therapy or redirecting patients to more effective treatment. The purpose of this study is to determine if the combination of longest diameter (LD) and functional tumor volume (FTV) from dynamic contrast enhanced (DCE-) MRI is superior to FTV alone or LD alone for assessing treatment response after neoadjuvant therapy in breast cancer patients.

Methods: Data from patients in the graduated drug arms of the I-SPY 2 trial were included in the analysis. Both LD and FTV were assessed using DCE-MRI after neoadjuvant therapy. LD was measured by the site radiologist as the longest dimension of the enhanced area on early post-contrast images. Functional tumor volume (FTV) was assessed as the sum of voxels with enhancement above specific thresholds within the pre-defined region-of-interest (ROI). A linearized variable was derived to represent the combination of FTV and LD. The area under the receiver operating characteristic curve (AUC) was used to evaluate the assessment of treatment response, pathologic complete response (pCR), defined as no invasive disease in the breast and lymph nodes, and in-breast pCR, defined as no invasive disease in the breast only. The analysis was performed in the full cohort and in breast cancer subtype defined by hormone receptor status and HER2 status.

Results: Among the patient cohort of N=675 with FTV and LD, 247 (37%) did and 428 (41%) did not achieve pCR after neoadjuvant therapy. pCR rates varied among HR/HER2 subtypes (HR+/HER2-: 19%; HR+/HER2+: 38%; HR-/HER2+: 71%; HR-/HER2- (triple negative, TN): 43%). In-breast pathologic complete response rates were slightly higher in each group (full: 41%; HR+/HER2-: 23%; HR+/HER2+: 43%; HR-/HER2+: 72%; HR-/HER2-: 49%). Table 1 shows AUCs for assessing pCR using FTV alone, LD alone, and the variable combining FTV and LD. Higher AUCs were observed in all patient groups using the combined variable. AUC of 0.79 (95% CI: 0.77, 0.81) was observed for the combined variable to assess pCR in the full cohort. AUCs varied from 0.69 to 0.86 among HR/HER2 subgroups (HR+/HER2-: 0.69; HR+/HER2+: 0.74; HR-/HER2+: 0.86; HR-/HER2-: 0.80), with no difference in assessing pCR or in-breast pCR. The performance is best for the HR- subtypes.

Conclusions: Both FTV and LD can be used in the assessment of invasive disease residual after neoadjuvant therapy. The combined variable of FTV and LD achieved highest AUCs, compared to using individual variable alone. Tools to improve performance in the HR+ subsets are underway.

AUCs of MR measurements for identifying pCR  FTV alone (95% CI)LD alone (95% CI)Combined (95% CI)FullWith subtype adj.0.73 (0.71, 0.75)0.77 (0.74, 0.79)0.79 (0.77, 0.81)FullWithout subtype adj0.69 (0.65, 0.73)0.72 (0.68, 0.76)0.75 (0.71, 0.79)HR+/HER2- 0.68 (0.60, 0.77)0.68 (0.59, 0.77)0.69 (0.61, 0.77)HR+/HER2+ 0.65 (0.56, 0.75)0.72 (0.64, 0.80)0.74 (0.66, 0.82)HR-/HER2+ 0.69 (0.55, 0.83)0.82 (0.71, 0.92)0.86 (0.77, 0.95)HR-/HER2- (TN) 0.72 (0.66, 0.79)0.73 (0.67, 0.80)0.80 (0.74, 0.85)

Citation Format: Li W, Newitt D, Yun BL, Kornak J, Joe B, Yau C, Abe H, Wolverton D, Crane E, Ward K, Nelson M, Niell B, Drukteinis J, Oh K, Brandt K, Bang DH, Ojeda H, Eghtedari M, Sheth P, Bernreuter W, Umphrey H, Rosen M, Dogan B, Yang W, Esserman L, Hylton N. MRI detection of residual disease following neoadjuvant chemotherapy (NAC) in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-03.

Oral delivery of fluticasone powder improves esophageal eosinophilic inflammation and symptoms in adults with eosinophilic esophagitis

Topical steroids are the primary medical therapy for eosinophilic esophagitis (EoE). Current steroid formulations are used off-label and designed for airway delivery. It is known that the efficacy of topical steroids depends on drug-mucosal contact time, which is related to its formulation. The purpose of this study is to examine the effectiveness of fluticasone administered by means of an orally administered powder formulation. We conducted a retrospective analysis of patients diagnosed with EoE based on current guidelines and who were treated with orally administered fluticasone powder. The primary outcome was histologic response (peak eosinophil density (eos/hpf)). Secondary outcomes included patient-reported symptoms (EoEQ) and endoscopic features measured by a validated instrument (EoE endoscopic reference score, EREFS). Forty patients were treated with fluticasone powder with doses of 500 to 1000 mcg b.i.d. A significant difference was found between pre- and posttreatment levels of eosinophilia (P < 0.0001). Seventy-five percent of patients achieved peak densities of <15 eos/hpf. Improvement was also demonstrated in dysphagia symptoms (P = 0.031) and endoscopic findings of furrows (P = 0.0001) and exudates (P = 0.0001). Oral fluticasone powder induced significant improvement in histopathology, symptoms, and endoscopic features of inflammation in adults with EoE. It offers an easy-to-administer formulation of a topical steroid that circumvents concerns with esophageal delivery of commonly used, aerosolized inhaler preparations.

Shortened therapy of eight weeks with paritaprevir/ritonavir/ombitasvir and dasabuvir is highly effective in people with recent HCV genotype 1 infection

Paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 12 weeks are approved for treatment of chronic HCV genotype 1 infection. This study assessed the efficacy of shortened duration paritaprevir/ritonavir/ombitasvir and dasabuvir with or without ribavirin for 8 weeks among people with recent HCV infection. In this open-label single-arm trial conducted in Australia, England and New Zealand, adults with recent HCV (duration of infection <12 months) received paritaprevir/ritonavir/ombitasvir and dasabuvir (with weight-based ribavirin for genotypes 1a and 1, no subtype) for 8 weeks. The primary endpoint was sustained virological response at 12 weeks post-treatment (SVR12) in the intention-to-treat (ITT) population. Thirty people (median age 38 years, male 93%) commenced treatment (with ribavirin, 97%), of whom 77% (n = 23) were HIV-positive, 93% (n = 28) had genotype 1a infection and 53% (n = 16) had ever injected drugs. Median maximum ALT in the preceding 12 months was 433 IU/L (IQR 321, 1012). Acute clinical hepatitis with ALT > 10 x ULN was documented in 83% (n = 25); one participant (3%) had jaundice. At baseline, median estimated duration of infection was 30 weeks (range 11, 51), and median HCV RNA was 5.7 log₁₀ IU/mL (range 2.7, 7.3). SVR12 was achieved in 97% (29/30; early discontinuation at week 2, n = 1; per protocol 100%, 29/29). No relapse or reinfection was observed. In conclusion, paritaprevir/ritonavir/ombitasvir and dasabuvir (with ribavirin) for eight weeks were highly effective among HIV-positive and HIV-negative individuals with recent HCV infection. These data support the use of this shortened duration direct-acting antiviral regimen in this population.

A high-throughput screen of real-time ATP levels in individual cells reveals mechanisms of energy failure

Insufficient or dysregulated energy metabolism may underlie diverse inherited and degenerative diseases, cancer, and even aging itself. ATP is the central energy carrier in cells, but critical pathways for regulating ATP levels are not systematically understood. We combined a pooled clustered regularly interspaced short palindromic repeats interference (CRISPRi) library enriched for mitochondrial genes, a fluorescent biosensor, and fluorescence-activated cell sorting (FACS) in a high-throughput genetic screen to assay ATP concentrations in live human cells. We identified genes not known to be involved in energy metabolism. Most mitochondrial ribosomal proteins are essential in maintaining ATP levels under respiratory conditions, and impaired respiration predicts poor growth. We also identified genes for which coenzyme Q10 (CoQ10) supplementation rescued ATP deficits caused by knockdown. These included CoQ10 biosynthetic genes associated with human disease and a subset of genes not linked to CoQ10 biosynthesis, indicating that increasing CoQ10 can preserve ATP in specific genetic contexts. This screening paradigm reveals mechanisms of metabolic control and genetic defects responsive to energy-based therapies.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.