When size really does matter - providing PrEP across Queensland

Background: Providing universal access to PrEP across Queensland, the 2nd largest and 3rd most populous state in Australia has provided unique challenges. Queensland has 22.5% of Australia’s total land area, compared to the 14.4% of New South Wales, Victoria and Tasmania combined. Queensland is also less centralised with 50% of the population living outside the state capital and 25% outside of the south eastern region. Notably, this population distribution is reflected in HIV diagnoses with 24% of new diagnoses in 2015 coming from Health Service Areas outside of the south east. Method: The unique service models, buildings, personalities, communities and clinical capacity of regional services has required bespoke solutions to implement QPrEPd in these sites. Many sites have not taken part in clinical trials before and required additional support. Additionally, the barriers to access found in more conservative services and communities has required the implementation team to advocate and educate for universal PrEP provision. Protocol modification has enabled nurses to manage ongoing PrEP provision in services with limited medical officer support. Results: Eleven study sites are outside of the south east corner; 7 public sexual health services, 3 general practices in Cairns and one Aboriginal Medical Service in Toowoomba. These sites have enrolled 18.5% of the all participants. The remaining 11 sites in the south east corner are include 5 general practices, including one run through a community based organisation, 5 public sexual health clinics and one private hospital. Overall, nearly 63% of the participants have enrolled at general practice sites. Conclusions: While this project has provided access to PrEP throughout much of Queensland, gaps remain. The key limitation in regional areas where there is no public sexual health service is the lack of S100 prescribing general practitioners. In order to expand access other service delivery models are being explored

Patient Perception of Lower Limb Non-Contrast Magnetic Resonance Angiography and Digital Subtraction Angiography in Diabetic Patients with Peripheral Arterial Disease

Objective: Non-contrast magnetic resonance angiography (NC-MRA) is an attractive technique for imaging peripheral arterial disease (PAD) in diabetic patients where arterial calcification and renal impairment are common. Our purpose was to evaluate patient perception of lower limb NC-MRA and compare this perception to that of digital subtraction angiography (DSA). Materials and Methods: Thirty-one diabetic patients (18 male, 13 female, mean age=69 years) with symptomatic PAD (critical ischemia, n=10) referred for DSA were prospectively recruited, and 1.5T quiescent-interval single-shot NC-MRA was performed before DSA (intervention performed during DSA, n=23). Patients rated anxiety, pain, discomfort, willingness to repeat (Likert scale: 1 most favorable to 7 least favorable), and difficulty compared to expectations (-3 better to +3 worse). Results: Twenty-nine patients’ results were analyzed (DSA under general anesthesia, n=1; incomplete NC-MRA due to morbid obesity, n=1). NC-MRA and DSA median scores were 1 vs. 3, 1 vs. 2, 2 vs. 2, and 1 vs. 1 for anxiety, pain, discomfort, and willingness to repeat, respectively. The median score for difficulty compared to expectations was 0 (as expected) for both examinations. The anxiety and pain scores for NC-MRA were significantly lower than those for DSA (p=0.006 and p=0.001, respectively). Reasons for the less favorable NC-MRA experience included machine noise (n=3), pain from coil pressure (n=3), and claustrophobia (n=1). Conclusion: NC-MRA was well tolerated overall, and better than DSA for anxiety and pain. Although DSA is commonly required for intervention in PAD, NC-MRA may inform disease management and potentially obviate DSA where conservative management, or open surgery, are indicated. Reduced acoustic noise, lighter receiver coils, and wider scan bores may improve procedural tolerance

Comprehensive arterial assessment in diabetic patients using combined quiescent interval single shot (QISS) imaging for leg imaging and QISS-arterial spin labeled MRA for pedal imaging: preliminary experience with comparison to DSA

Target Audience Clinicians and basic scientists with an interest in non-invasive imaging of peripheral arterial disease. Purpose Imaging diabetic patients with peripheral arterial disease (PAD) is critical for revascularization planning. PAD in diabetic patients is commonly distal, and imaging of the pedal arteries is desirable to identify potential bypass targets. Concomitant renal impairment may contribute to difficulties with conventional imaging. Quiescent interval single shot (QISS) MRA is a recently described non-contrast enhanced technique with high reported accuracy. However, it is challenging to perform in the feet, due to inhomogeneous shim and slow arterial flow, with QISS with arterial spin labeling (QISS-ASL) described to improve pedal artery visualization. The purpose of this study was to evaluate feasibility and accuracy of a combined QISS/QISS-ASL approach (cQISS-MRA) for evaluating diabetic patients with symptomatic PAD, using DSA as the reference standard. Methods 15 diabetic patients (7M, 8F, mean 72y, range 42-91y, eGFR 7-91 ml/min/1.73m2) with symptomatic PAD were prospectively recruited for cQISS-MRA at 1.5T (Siemens, Avanto) 0-36 days prior to clinically required DSA. Initially, pedal QISS-ASL MRA was performed with a 12-channel head coil. Subsequently, QISS MRA of infrarenal aorta to feet was performed with peripheral, body and spine array coils. Common parameters for QISS MRA and QISS-ASL MRA were: FA 90°, in plane resolution 1 x 1mm2, BW 658 Hz/Px, acceleration factor 2 (GRAPPA). For QISS MRA: TR/TE 3.5/1.4ms, sl 3mm (additional 1.2mm imaging through calf), FOV 400 x 260, 9 stations, 48 sl, total acquisition 432 RR intervals, quiescent interval 350ms. For QISS-ASL: TR/TE 3.7/1.6ms, quiescent interval 228ms, FOV 400 x 240, sl 1.2mm, 2 stations, 128 sl, total acquisition 256 RR intervals. DSA was performed with iodinated contrast (n=14) or carbon dioxide (CO2, n=1) with coverage determined by clinical indication. MRA and DSA images were anonymized and evaluated by a cardiovascular and vascular/interventional radiologist respectively on a PACS workstation (Impax, Agfa). Diagnostic confidence (1=non- diagnostic, 3=diagnostic, 5=highly confident) was recorded and compared with the Wilcoxon signed rank test. MRA diagnostic confidence was compared between regions (pelvis, thigh, calf and foot) with the Mann-Whitney U test. Segmental stenosis was graded in up to 39 segments per patient. cQISS- MRA sensitivity and specificity for hemodynamically significant (≥50%) stenosis was calculated against DSA for all available segments. Results Imaging was completed in 13/15 patients with 2 incomplete studies (BMI 40 precluding imaging of pelvis and thigh, n=1; patient discomfort, n=1). DSA correlation (Fig 1) was available in 19 legs in 15 patients, with pelvic DSA only in 1 patient. For all segments where DSA was available, cQISS-MRA mean diagnostic confidence was 4.00±0.96, significantly higher than DSA 3.72±0.84, p<0.0001, with 12 non-diagnostic (score of 1) DSA segments at CO2 angiography, and 5 non-diagnostic MRA segments (susceptibility from joint prostheses). For cQISS-MRA, there was significantly lower diagnostic confidence in the foot compared with other regions (pelvis 3.87±0.93, thigh 4.0±1.0, calf 4.2±0.77, foot 2.41±1.1, p<0.0001 for all regions compared to the foot). Factors negatively impacting MRA diagnostic confidence and accuracy were: for QISS- MRA, step artifact from motion/ mistriggering and inhomogeneous fat suppression; for QISS-ASL MRA, motion artifact and image noise. Excluding non-diagnostic DSA and MRA segments, 309 segments were assessed for stenosis, with 142 (46.0%) demonstrating hemodynamically significant stenosis. Overall, there was 74.7% sensitivity and 86.8% specificity for cQISS-MRA, highest for aortoiliac segments, and lowest for pedal segments (Table 1). Discussion/ Conclusion A combined QISS MRA and QISS-ASL MRA approach is feasible for infrarenal aorta to pedal arterial assessment in diabetic patients with symptomatic PAD. There is good diagnostic confidence for pelvic to calf imaging and lower diagnostic confidence for pedal imaging. Accuracy of the technique is higher for proximal stations, with susceptibility artifact and inhomogeneous fat suppression impacting stenosis assessment. Pedal imaging is degraded by motion and relatively low SNR, however still enables identification of potential distal bypass targets in a patient population with a substantial burden of disease. This includes patients with end stage renal failure, where even DSA may be challenging. Assessment of potential clinical utility of cQISS-MRA for guiding management is planned. Further refinements to accelerate QISS-ASL MRA, and strategies to improve robustness to motion, including non-Cartesian acquisition, could improve test accuracy for pedal arterial stenosis

"From Top to Bottom" – Queensland Pre-Exposure Prophylaxis (QPrEPd) demonstration trial and sexually transmitted infections

Background: In the eighth month since the QPrEPd project rolled out across Queensland, 22 clinical sites have recruited 1695 participants. This paper describes the prevalence of sexually transmitted infections (STIs) in QPrEPd participants at three monthly time points. Methods: At each time point participants undergo blood testing for HIV and syphilis, urine PCR and pharyngeal swabs and where indicated, anal swabs, for chlamydia and gonorrhoea. Results: Five participants tested positive for HIV at the screening visit and were all tested at south east Queensland sites. Of the 1,394 participants who completed the entry survey, a third identified that they had not had an HIV screening test within the past 3 months. Of greater concern is the 2.4% who had not been screened within the past 2 years and the 1% who had never been screened in this high risk for HIV population. At screening 12.8% of participants had one or more STIs with little difference at three months (11.3%), however almost half of the three month results are yet to be reported. Interestingly at six months the anal chlamydia prevalence at 9.1% is almost double the 4.5% at screening but this trend may reflect a higher risk of early enrolees and could change once all results have been received. 15% of STI tests conducted at the 11 sites outside of the Queensland south east corner were positive compared to 8.6% in the 11 south east sites. Conclusion: The preliminary results reveal that a substantial proportion of the population at high risk of HIV acquisition are not following the Australian recommendation of 3 monthly screening. Over time we will explore the regional differences in HIV and STI prevalence and the seeming increasing trend in anal chlamydia

PrEP, sweat and tears: challenges for the Queensland QPrEPd Operation Team

Background: In 2015 cairns Sexual Health Services (CSHS) successfully implemented QPrEP across 6 sites providing 50 participants PrEP for a 12 month period. In April 2016 the Queensland Minister for Health, and Ambulance Services, instructed the CSHS to expand this project to 2000 participants with the explicit expectation of commencement within 6 months

How was it for you? The first three months on the Queensland Pre-Exposure Prophylaxis (QPrEPd) demonstration trial

Background: In the eighth month since the QPrEPd project rolled out across Queensland, 22 clinical sites have recruited 1695 participants. This paper describes the pattern of pill taking and experiences of participants from enrolment to month three. Methods: Surveys undertaken by participants were confidential. In order to encourage honesty, clinicians did not have access to their clients' responses. Data was analysed descriptively and results were compared between entry and 3 month visits. Results: 832 QPrEPd participants have completed the 3 month survey. 70% of participants felt more sexually empowered whilst taking PrEP. Patients preferred to take their PrEP medication in the morning, 87% found the pills "completely acceptable" and 81% of participants were completely comfortable taking pills. Interestingly, 69% of participants took their pills on a regular basis and 92% reported good compliance by taking their pills every day between study visits. Only 7.8% of participants preferred to take intermittent PrEP rather than continuous daily doses and 83% of these participants used condoms during the period they were intentionally not taking PrEP. 68% of participants surveyed never reported any side effects with their PrEP, whilst only 2.5% reported side-effects "most" or "all of the time". Surprisingly, 77% of participants did not increase their number of sexual partners, 31% reported that PrEP did not change their sex life and only 28.3% agreed that taking PrEP changed their sexual risk taking behaviour. 81% strongly agreed "STI checks are needed every 3 months while taking PrEP" and only 2.1% "strongly disagreed" with this statement. Conclusion: So far QPrEPd has found that participants are proactive in preventing HIV, whilst still enjoying their sexual freedom. It will be exciting to see how the result patterns unravel during the demonstration project over the next few years

Accuracy of non-contrast quiescent-interval single-shot and quiescent-interval single-shot arterial spin-labelled magnetic resonance angiography in assessment of peripheral arterial disease in a diabetic population

INTRODUCTION: Diabetic patients with peripheral arterial disease (PAD) are challenging to assess. Non-contrast magnetic resonance angiography (MRA) offers a safe alternative in patients with renal impairment. The study objective is to evaluate accuracy of lower limb quiescent-interval single-shot (QISS) MRA and pedal QISS-arterial spin-labelled (ASL) MRA for detection of significant stenosis in diabetic patients with PAD. METHODS: Combined QISS and QISS-ASL MRA was performed in 32 diabetic PAD patients (20 male, 12 female; mean 69 years; 8 with critical ischaemia). Two readers assessed haemodynamically significant (>50%) stenosis and diagnostic confidence on MRA, against digital subtraction angiography (DSA) as the reference standard, with subgroup analysis of patients with severe renal impairment (n = 7). Inter-reader agreement of stenosis and diagnostic confidence were evaluated. Test-retest reproducibility was evaluated in 10 subjects who underwent repeat MRA on a different day. RESULTS: At DSA, 262/645 segments (40.6%) had haemodynamically significant stenoses. MRA accuracy was 78.1% (478/612) and 75.6% (464/614), sensitivity 64.7% (161/249) and 77.5% (193/249), and specificity 87.3% (317/363) and 74.2% (271/365) for 2 readers. MRA accuracy was 80.9% and 80.7% for readers 1 and 2, respectively, in patients with severe renal impairment. QISS MRA but not pedal QISS-ASL MRA was considered of diagnostic image quality. Inter-reader agreement was moderate for stenosis (ĸ = 0.60) and diagnostic confidence (ĸ = 0.41). Test-retest reproducibility was high (ĸ = 0.87) and moderate (ĸ = 0.54) for individual readers. CONCLUSIONS: Quiescent-interval single-shot MRA has reasonable accuracy in a diabetic PAD population with high burden of disease, providing a non-contrast option in patients with renal impairment. QISS-ASL MRA requires further optimisation to be clinically feasible