Antiretroviral Therapy for Prevention of Human Immunodeficiency Virus Infection

A global review of national guidelines of post-exposure prophylaxis for the prevention of HIV

INTRODUCTION

The World Health Organization (WHO) recommends the use of antiretroviral drugs as post-exposure prophylaxis (PEP) for preventing HIV acquisition for occupational and non-occupational exposures. To inform the development of global WHO recommendations on PEP, we reviewed national guidelines of PEP for their recommendations.

METHODS

Policies addressing PEP from 38 WHO HIV priority countries were obtained by searching governmental and non-governmental websites and consulting country and regional experts; these countries were selected based on HIV burden, new HIV acquisitions and the number of HIV-associated deaths. We reviewed national guidelines to collate data on where PEP can be offered, who can prescribe PEP, PEP eligibility, recommended drug regime, linkage to other interventions, recommended investigations prescribed with PEP, HIV self-test recommendation related to PEP and stopping rules for PEP.

RESULTS

In total, 46 guidelines from January 2010 to May 2023 across 36 countries were included, with 70% of documents published during or after 2020. There was significant variation across national guidelines regarding where PEP can be accessed and who can provide or prescribe PEP. Six countries (17%) described being able to access PEP from a primary care facility, four countries (11%) from hospitals and two (6%) from community-based services. Only three countries (8%) specifically considered dispensing PEP by professionals other than doctors (e.g. nurses). None mentioned pharmacists as prescribers. We found a lack of consistency across countries regarding who is eligible for PEP, regimens used, interventions integrated into PEP provision and recommended investigations for PEP users. No country guidance provided considerations on using HIV self-tests for starting or stopping PEP.

DISCUSSION

Despite PEP being recommended for more than three decades, many national policies were lacking in terms of PEP guidance. There are opportunities for countries to update and optimize guidance to consider ways to improve the accessibility of PEP. Greater efforts are needed to support the development of global consensus on how best to implement and integrate PEP, as well as how to include decentralization and task-sharing to achieve sufficient scale for impact.

CONCLUSIONS

Improving timely access to PEP and promoting PEP adherence could help contribute to reducing the incidence of HIV globally.

A Combination of Novel HIV-1 Protease Inhibitor and Cytochrome P450 (CYP) Enzyme Inhibitor to Explore the Future Prospective of Antiviral Agents: Evotaz

Viruses belong to the class of micro-organisms that are well known for causing infections in the human body. Antiviral medications are given out to prevent the spread of disease-causing viruses. When the viruses are actively reproducing, these agents have their greatest impact. It is particularly challenging to develop virus-specific medications since viruses share the majority of the metabolic functions of the host cell. In the continuous search for better antiviral agents, the United States Food and Drug Administration (USFDA) approved a new drug named Evotaz on January 29, 2015 for the treatment of human immunodeficiency virus (HIV). Evotaz is a combined once-daily fixed drug, containing Atazanavir, an HIV protease inhibitor, and cobicistat, an inhibitor of the human liver cytochrome P450 (CYP) enzyme. The medication is created such that it can kill viruses by concurrently inhibiting protease and CYP enzymes. The medicine is still being studied for a number of criteria, but its usefulness in children under the age of 12 is currently unknown. The preclinical and clinical characteristics of Evotaz, as well as its safety and efficacy profiles and a comparison of the novel drug with antiviral medications presently available in the market, are the main topics of this review paper.

Human Immunodeficiency Viruses and its effect on the Pulmonary Vascular bed

December. 1^st 2021 is "World AIDS Day" reminding us that HIV infection is still widespread and that many of its long-term effects can be deadly. One of these complications is its effect on the pulmonary vascular beds, leading to an increase in the pulmonary pressure, causing the clinical manifestation of "pulmonary hypertension". Unfortunately, we are still far from fully understanding the prevalence, mechanics, and pathobiology of "HIV pulmonary hypertension", especially in Africa and other developing countries where HIV is still common. In addition, the impact of other factors like co-infection and illicit drugs can add and modify the effect on the pulmonary vascular bed, complicating the pathological and clinical effects of HIV. Thus, "World AIDS Day" can be an impetus to pursue further research in this area.

Emergency Room "Opt-Out" HIV Testing Pre- and During COVID-19 Pandemic in a Large Community Health System

Background:

South Florida has the highest HIV rates across the country. Emergency Rooms (ERs) are optimal clinical sites for the identification of people living with HIV. We aimed to evaluate the feasibility and yield of opt-out HIV testing among ER patients in a large community healthcare system in South Florida, and determine the impact of the COVID-19 pandemic on HIV testing.

Methods:

This was a retrospective study conducted in the Memorial Healthcare System, Hollywood, Florida. HIV test was offered on an “opt-out” basis to patients aged 16 years or older presenting to the ER of the Memorial Regional Hospital between July 2018 and August 2020. Number of ER visits, HIV testing offered, acceptance of HIV testing, tested positive for HIV infection and linkage to care were reviewed and analyzed.

Results:

A total of 105,264 (53.7%) patients of 196,110 ER visits were eligible for HIV testing and 39,261 (37.3%) completed HIV testing. Of those tested, 206 (0.5%) patients tested positive, with 54 (26.2%) new infected patients and 152 (73.8%) known infected patients who had not disclosed their status. 45 (60%) of 75 patients with known HIV infections who were not engaged in HIV care were successfully relinked into care after testing, and engagement in care increased from 50.7% pre-testing to 80.3% post-testing (p = 0.001). 45 (83.3%) of 54 newly diagnosed patients were successfully linked into care. During the COVID-19 pandemic, there was a significant reduction in both the ER visits and HIV tests as compared with the pre-pandemic period (p = 0.007 and p < 0.001, respectively).

Conclusion:

An “Opt-out” HIV testing program was successfully implemented in a community hospital ERs. The use of this strategy successfully identified patients with undiagnosed HIV infection and improved their engagement in HIV care. Given the impact of COVID-19 pandemic on the testing program, new strategies should develop to reduce service disruption and maintain the progress of “Opt-out” HIV testing.

Apoptosis of Hepatocytes: Relevance for HIV-Infected Patients under Treatment

Due to medical advances over the past few decades, human immunodeficiency virus (HIV) infection, once a devastatingly mortal pandemic, has become a manageable chronic condition. However, available antiretroviral treatments (cART) cannot fully restore immune health and, consequently, a number of inflammation-associated and/or immunodeficiency complications have manifested themselves in treated HIV-infected patients. Among these chronic, non-AIDS (acquired immune deficiency syndrome)-related conditions, liver disease is one of the deadliest, proving to be fatal for 15–17% of these individuals. Aside from the presence of liver-related comorbidities, including metabolic disturbances and co-infections, HIV itself and the adverse effects of cART are the main factors that contribute to hepatic cell injury, inflammation, and fibrosis. Among the molecular mechanisms that are activated in the liver during HIV infection, apoptotic cell death of hepatocytes stands out as a key pathogenic player. In this review, we will discuss the evidence and potential mechanisms involved in the apoptosis of hepatocytes induced by HIV, HIV-encoded proteins, or cART. Some antiretroviral drugs, especially the older generation, can induce apoptosis of hepatic cells, which occurs through a variety of mechanisms, such as mitochondrial dysfunction, increased production of reactive oxygen species (ROS), and induction of endoplasmic reticulum (ER) stress and unfolded protein response (UPR), all of which ultimately lead to caspase activation and cell death.

Updates on HIV nonoccupational postexposure prophylaxis

PURPOSE OF REVIEW

Adolescents and young adults continue to contribute to new HIV infections despite improved antiretroviral regimens and HIV preexposure and postexposure prophylaxis (PrEP and PEP). Knowledge about nonoccupational HIV PEP (nPEP) is relevant and important for all pediatricians as adolescents present under a variety of circumstances disclosing past sexual activity.

RECENT FINDINGS

nPEP is effective in preventing HIV infection, and newer regimens have been shown to increase compliance amongst users, have less side effects, and lead to less HIV resistance. Yet, research on physician prescription practices shows a lack of knowledge regarding appropriate HIV nPEP medication regimens, dosing, and follow-up recommendations. Updated national guidelines are available to providers who may be unfamiliar with indications and drug regimens for nPEP. Studies also provide different strategies to increase nPEP use and compliance among patients as well as ways to increase provider awareness of appropriate nPEP prescription.

SUMMARY

Research of HIV nPEP shows that it is effective when used correctly, but there needs to be increased education and awareness to increase provider prescription and patient use as well as institutional changes to help patients complete the full course of medication.

Toxicity and genotoxicity induced by abacavir antiretroviral medication alone or in combination with zidovudine and/or lamivudine in Drosophila melanogaster

Abacavir (ABC), zidovudine (AZT), and lamivudine (3TC) are nucleoside analog reverse transcriptase inhibitors (NRTIs) widely used as combination-based antiretroviral therapy against human immunodeficiency virus. Despite effective viral suppression using NRTI combinations, genotoxic potential of NRTIs can be increased when administered in combination. This study investigated the toxic and genotoxic potential of ABC when administered alone or in combination with AZT and/or 3TC using the somatic mutation and recombination test in Drosophila melanogaster. This test simultaneously evaluated two events related to carcinogenic potential: mutation and somatic recombination. The results indicated that ABC was responsible for toxicity when administered alone or in combination with AZT and/or 3TC. In addition, all treatment combinations increased frequencies of mutation and somatic recombination. The combination of AZT/3TC showed the lowest genotoxic activity compared to all combinations with ABC. Therefore, our results indicated that ABC was responsible for a significant portion of genotoxic activity of these combinations. Somatic recombination was the main genetic event observed, ranging from 83.7% to 97.7%.

Antiretroviral Drug Use and HIV Drug Resistance Among Young Women in Rural South Africa: HPTN 068

BACKGROUND

Antiretroviral (ARV) drugs are used for HIV treatment and prevention. We analyzed ARV drug use and HIV drug resistance in a cohort of young women in rural South Africa enrolled in the HIV Prevention Trials Network (HPTN) 068 study, which evaluated the use of a cash transfer conditional on school attendance to reduce HIV incidence.

METHODS

ARV drug testing was performed using plasma samples from 2526 young women. This included 2526 enrollment samples (80 HIV-infected and 2446 HIV-uninfected) and 162 seroconversion samples (first HIV-positive study visit). Testing was performed using a qualitative assay that detects 20 ARV drugs from 5 drug classes. HIV drug resistance testing was performed with the ViroSeq HIV-1 Genotyping System for samples that had HIV viral loads ≥400 copies per milliliter.

RESULTS

At enrollment, ARV drugs were detected in 10 (12.5%) of 80 HIV-infected young women. None of 2446 HIV-uninfected young women had ARV drugs detected at enrollment. ARV drugs were also detected in 16 (9.9%) of 162 seroconverters. At enrollment, 9 (13.4%) of 67 young women with genotyping results had HIV drug resistance; resistance was also detected in 9 (6.9%) of 131 seroconverters with genotyping results.

CONCLUSIONS

Most of the HIV-infected young women in this cohort from rural South Africa were not taking ARV drugs, suggesting they were unaware of their HIV status or were not in care. HIV drug resistance was detected in young women with both prevalent and new HIV infection.

University of North Carolina/Emory Center for Innovative Technology (iTech) for Addressing the HIV Epidemic Among Adolescents and Young Adults in the United States: Protocol and Rationale for Center Development

Background

Over a fifth of all new HIV infections in the United States occur among persons aged 13 24 years, with most of these diagnoses occurring among gay and bisexual males (81%). While the epidemic of HIV in the United States has leveled off for many age groups, the annual number of new HIV diagnoses among young men who have sex with men (YMSM; 13-24 years old) remains high. Traditional approaches to continuum improvement for youth have been insufficient, and targeted interventions are urgently needed for young people at risk for or infected with HIV. Interventions delivered through mobile health technology represent a promising approach for improving outcomes in this population. Mobile phones have nearly reached saturation among youth, making mobile technology a particularly promising tool for reaching this population.

Objective

The University of North Carolina/Emory Center for Innovative Technology (iTech) is a National Institutes of Health cooperative agreement as part of the Adolescent Medicine Trials Network for HIV/AIDS Interventions. iTech aims to impact the HIV epidemic by conducting innovative, interdisciplinary research on technology-based interventions across the HIV prevention and care continuum for adolescents and young adults in the United States, particularly YMSM, by providing the following: (1) evaluation of novel approaches to identifying youth with undiagnosed HIV infections; (2) evaluation of multilevel, combination prevention approaches, particularly relevant to gender- and sexual-minority youth facing co-occurring health risks; (3) evaluation of uptake of and adherence to biomedical prevention modalities; and 4) evaluation of interventions designed to promote or optimize engagement in care and antiretroviral therapy adherence in HIV-positive youth, to optimize viral load suppression.

Methods

iTech brings together multidisciplinary experts in the fields of adolescent HIV treatment and prevention, development and evaluation of technology-based interventions, HIV surveillance and epidemiology, and intervention design and evaluation. This initiative will support 8 efficacy trials and 2 exploratory projects, each led by 2 principal investigators. Taken together, the studies address all of the key steps of the HIV prevention and care continuum for youth in the United States. Each proposal uses technology in a scientifically rigorous and innovative way to access, engage, and impact at-risk or infected youth. Nine iTech subject recruitment venues are spread across 8 US cities. Three cores (management, analytic, and technology) support all iTech activities and form the research network’s infrastructure, facilitating all aspects of study implementation and evaluation.

Results

Formative work has already begun on many of the above-mentioned iTech trials. We expect the first randomized controlled trials to begin in mid-2018. Additional details can be found in the individual intervention protocol papers in this issue.

Conclusions

Through its comprehensive research portfolio, iTech aims to effectively advance HIV prevention and care for youth through technology-based, youth-relevant interventions that maximize adaptability and sustainability.

Registered Report Identifier

RR1-10.2196/10365