Post-exposure prophylaxis after occupational and non-occupational exposures to HIV: an overview of the policies implemented in 27 European countries

An open-label evaluation of safety and tolerability of coformulated bictegravir/emtricitabine/tenofovir alafenamide for post-exposure prophylaxis following potential exposure to human immunodeficiency virus-1

BACKGROUND

Single-tablet regimen (STR) provides a convenient once-daily regimen for the prevention of human immunodeficiency virus (HIV) infection. Here, we investigated the safety and tolerability of coformulated bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) as a three-drug, STR for post-exposure prophylaxis (PEP) in Chinese individuals.

METHODS

This was a prospective, open-label, single-arm trial conducted in a sexually transmitted diseases and acquired immunodeficiency syndrome clinic of a tertiary hospital in Beijing, China. Adults requiring PEP were prescribed BIC/FTC/TAF one pill once a day for 28 days. Clinical and laboratory data were collected and analyzed at baseline, weeks 2, 4, 8, 12, and 24.

RESULTS

Of 112 participants enrolled in the study, 109 (97.3%) were male and the mean age was 30 ± 8 years. PEP completion was 96.4% (95% confidence interval: 91.1-99.0%). Two participants stopped PEP after 2 days because the source partner was identified as HIV uninfected. One participant was excluded due to hepatitis B virus infection according to the exclusion criteria. One discontinued due to the participant's decision. No participant acquired HIV through week 24. Adherence was 98.9% (standard deviation [SD]: 3.3%) by self-reporting and 98.5% (SD: 3.5%) by pill count. Only five participants experienced mild clinical adverse events attributed to the study drug (including headache, diarrhea, and nausea) and four participants had elevated serum creatinine (grade 1).

CONCLUSIONS

A once daily, STR of BIC/FTC/TAF used as PEP was safe and well-tolerated with a high rate of completion and adherence in Chinese. BIC/FTC/TAF may be a good option for PEP.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR2100048080.

Current Perspectives on the Determinants of Acceptability of Pre-Exposure Prophylaxis and Nonoccupational Post-Exposure Prophylaxis among People at Risk for HIV: A Scoping Review

Pre-exposure prophylaxis (PrEP) and nonoccupational post-exposure prophylaxis (nPEP) were found to be effective HIV biomedical interventions. However, several barriers to acceptance of these interventions were discovered among populations at risk for HIV, and the Coronavirus Disease 2019 (COVID-19) pandemic may also exacerbate these. The current scoping review aims to update information in regards to facilitators and barriers for PrEP and nPEP acceptability among key populations collected in the past two years and to identify any existing knowledge gaps during the time of the COVID-19 pandemic. Of 1453 studies retrieved, 16 met the final inclusion criteria. The review synthesized a range of individual, PrEP-specific, psychosocial, and health system factors that may affect the acceptability of PrEP or nPEP. The conclusion from this scoping review is that more research is needed to enable a comprehensive understanding of the determinants of acceptability of PrEP and nPEP in the context of COVID-19, particularly among PWID and FSWs.

Standardizing HIV post-exposure prophylaxis in the emergency department following sexual assault

OBJECTIVES

A standardized non-occupational post-exposure prophylaxis (nPEP) programme was implemented to improve guideline compliance for treatment of post-sexual assault patients within an emergency department (ED).

METHODS

A single-centre, retrospective, observational study of adult patients evaluated in the ED for sexual assault was performed following nPEP programme implementation. A comprehensive nPEP programme consisting of a standardized order set, real-time multidisciplinary consultation, on-site pharmacy and close post-discharge follow-up was implemented between July 2017 and June 2018. Laboratory, treatment, vaccination, prescription and follow-up data during the pre- (July 2016 to June 2017) and post-intervention (July 2018 to August 2019) periods were compared.

RESULTS

Of the 147 post-sexual assault patients included in this study (59 pre-intervention, 88 post-intervention), 133 (90.5%) were eligible for nPEP. Patient demographics and rate of those eligible for nPEP were similar in both cohorts. Antiretroviral therapy (ART) was offered (72.2% vs. 100%; p < 0.005) and ultimately prescribed (51.9% vs. 86.1%; p < 0.005) more frequently following nPEP programme implementation. Patients were more likely to have appropriate screening for renal function, liver function, pregnancy, syphilis, hepatitis B, hepatitis C and HIV in the post-intervention period (all p < 0.005). Hepatitis B vaccination was more commonly administered post-intervention (8.5% vs. 22.7%; p < 0.024). In-person 28-day follow-up was rare in both pre- (3.5%) and post-intervention (11.3%) cohorts (p = 0.278).

CONCLUSIONS

Implementation of a comprehensive nPEP programme resulted in improved guideline compliance with more frequent and appropriate ART administration. Recommended screening laboratories and hepatitis B vaccinations were more commonly performed, but in-person follow-up remained low. The nPEP programmes should be implemented to standardize efforts that decrease the risk of HIV transmission.

Non-Occupational HIV Post-exposure Prophylaxis: A 10-Year Retrospective Review of Data Following Sexual Exposure From Yaounde Central Hospital, Cameroon

BACKGROUND

Human Immunodeficiency Virus (HIV) post exposure prophylaxis (PEP) consists of administering antiretroviral therapy within 72 hours of viral exposure and continued for four weeks. PEP has been shown to be an important means of preventing and decreasing the number of new HIV infections in the general population. The purpose of this study was to describe the profile of patients who consulted at the HIV/AIDS Care and Treatment Center of the Yaounde Central Hospital (YCH) for PEP following non-occupational exposure to HIV. To attain our objective, we carried out a 10-year retrospective review of patient records of all persons who consulted for accidental HIV exposure at the YCH, Cameroon.

METHODS

This study was an observational, retrospective analysis of hospital records of persons who consulted for PEP following accidental exposure to HIV in the outpatient HIV clinic at YCH between January 2007 and December 2016. Data extracted from patients' records were: type of HIV exposure, sex, age, profession, level of education, HIV status of source and time to consultation. Descriptive and inferential statistics were analyzed using STATA IC 12.0. Results were presented as median and interquartile range for continuous variables. Categorical variables were expressed as frequencies and proportions.

RESULTS

There were 628 consultations for PEP of which 48% (299/628) were as a result of non-occupational post exposure prophylaxis (nPEP). Of those who consulted for HIV PEP following non-occupational exposure, 78% (234/299) were females; adolescents group (15-19 years) and young adults group (20 - 24yrs.) constituted 41% (125/299). Forty percent (1208/299) were secondary or high school students (level of education) and 88% (262/299) were non-healthcare workers. The median time-to-consultation for non-occupational PEP (nPEP) was 19 hours (IQR: 12.4-25.0) and HIV status of the source was unknown in 64% (191/299) of cases and positive for 8% (25/299) of cases. The most frequent indications for consulting were sexual assault, 75% (224/299); condom slippage or breakage, 10% (30/299); and unprotected consensual sexual intercourse, 15% (45/299).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Consultations for nPEP are as frequent as those occupational PEP (48% vs 52% in this study) in clinical practice at YCH. A good history of the source is important as it prevents unnecessary prescriptions of ART (which themselves have potential side effects) for persons consulting for potential HIV non-occupational exposure. In our study, we found that 27% (82/299) unnecessary ART prescriptions were avoided by determining that the exposure source person had negative HIV status. In addition, adolescent or young females consulting for nPEP in clinics could be potential victims of sexual assault or gender-based violence. Where possible, we recommend that clinicians consider the source of suspected viral exposure in clinical practice prior to administering ART for PEP.

Pre-exposure prophylaxis (PrEP) in an era of stalled HIV prevention: Can it change the game?

Pre-exposure prophylaxis (PrEP) for HIV prevention has evolved significantly over the years where clinical trials have now demonstrated the efficacy of oral PrEP, and the field is scaling-up implementation. The WHO and UNAIDS have made PrEP implementation a priority for populations at highest risk, and several countries have developed guidelines and national plans accordingly, largely based on evidence generated by demonstration projects. PrEP presents the opportunity to change the face of HIV prevention by offering a new option for protection against HIV and disrupting current HIV prevention systems. Nevertheless, as with all new technologies, both practical and social requirements for implementation must be taken into account if there is to be sustained and widespread adoption, which will also apply to forthcoming prevention technologies. Defining and building success for PrEP within the scope of scale-up requires careful consideration. This review summarises where the PrEP field is today, lessons learned from the past, the philosophy and practicalities of how successful programming may be defined, and provides perspectives of costs and affordability. We argue that a successful PrEP programme is about effective intervention integration and ultimately keeping people HIV negative.

Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): protocol for a pragmatic clinical trial at public healthcare clinics in Brazil

INTRODUCTION

Few results from programmes based on combination prevention methods are available. We propose to analyse the degree of protection provided by postexposure prophylaxis (PEP) for consensual sexual activity at healthcare clinics, its compensatory effects on sexual behaviour; and the effectiveness of combination prevention methods and pre-exposure prophylaxis (PrEP), compared with exclusively using traditional methods.

METHODS AND ANALYSIS

A total of 3200 individuals aged 16 years or older presenting for PEP at 5 sexually transmitted disease (STD)/HIV clinics in 3 regions of Brazil will be allocated to one of two groups: the PEP group-individuals who come to the clinic within 72 h after a sexual exposure and start PEP; and the non-PEP group-individuals who come after 72 h but within 30 days of exposure and do not start PEP. Clinical follow-up will be conducted initially for 6 months and comprise educational interventions based on information and counselling for using prevention methods, including PrEP. In the second study phase, individuals who remain HIV negative will be regrouped according to the reported use of prevention methods and observed for 18 months: only traditional methods; combined methods; and PrEP. Effectiveness will be analysed according to the incidence of HIV, syphilis and hepatitis B and C and protected sexual behaviour. A structured questionnaire will be administered to participants at baseline and every 6 months thereafter. Qualitative methods will be employed to provide a comprehensive understanding of PEP-seeking behaviour, preventive choices and exposure to HIV.

ETHICS AND DISSEMINATION

This study will be conducted in accordance with the resolution of the School of Medicine Research Ethics Commission of Universidade de São Paulo (protocol no. 251/14). The databases will be available for specific studies, after management committee approval. Findings will be presented to researchers, health managers and civil society members by means of newspapers, electronic media and scientific journals and meetings.

Sustainability of an HIV PEP Program for Sexual Assault Survivors: "Lessons Learned" from Health Care Providers

This study explored challenges to continuing an HIV post-exposure prophylaxis (PEP) program of care provided to sexual assault survivors in the province of Ontario, Canada. Data were collected as part of an implementation and evaluation of a universal offering of HIV PEP (known as the HIV PEP Program) at 24 of 34 provincial hospital-based sexual assault treatment centres. Experienced health care providers were surveyed (n = 132) and interviewed in four focus groups (n = 26) about their perceptions of what, if any, factors threatened their ability to maintain the HIV PEP Program. All focus groups were audio-recorded and the recordings transcribed. The transcriptions and open-ended survey responses were analyzed using content analysis. Administrator, nurse, physician, social worker, and pharmacist respondents perceived important barriers to sustainability of the HIV PEP Program. Eight constructs were identified within four broad themes: resources (inadequate funds, overworked and unacknowledged staff), expertise (insufficient external supports, insufficiently trained and knowledgeable staff), commitment (lack of institutional support, physician resistance to offering HIV PEP), and accommodation (lack of flexibility in addressing specific client and community needs, inaccessibility and lack of clarity of tools). We discuss the implications of these findings and the actions that were taken to address the challenges.

Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries

OBJECTIVES

To describe characteristics and management of people with community acquired needle stick injuries (CANSI) attending urban emergency departments; and suggest a guideline to improve assessment, management, and documentation.

METHODS

A retrospective analysis of cases with CANSI attending emergency departments in two tertiary hospitals between 2001 and 2005 using medical record review with follow up phone and written survey.

RESULTS

Thirty-nine cases met the criteria for CANSI. Persons younger than 30 years sustained 48.72% of all injuries. Source serology was available for only five cases (12.82%). Thirty-one of thirty-nine patients (79.49%) were classed as not immune to hepatitis B but only four of these (12.90%) received both hepatitis B vaccination and hepatitis B immunoglobulin. Six patients (15.38%) received HIV prophylaxis; of which two (33.33%) did not receive baseline HIV testing. Of ten patients referred to immunology clinic for follow up only two (20.00%) attended at 6 months.

CONCLUSION

We have identified groups that are at high risk of CANSI, including young males, security workers and cleaners. In the majority of cases protection against hepatitis B was inadequately provided, and a substantial proportion had inadequate baseline assessment and documentation. A guideline is suggested that may be used to improve these deficits.

Evaluation of 4 weeks' neonatal antiretroviral prophylaxis as a component of a prevention of mother-to-child transmission program in a resource-rich setting

BACKGROUND

In resource-rich settings, universal adoption of a 4- rather than 6-week neonatal antiretroviral (ARV) prophylaxis regimen could reduce toxicity and results in cost savings, provided prevention of mother-to-child transmission program effectiveness is not compromised.

METHODS

Between January 1999 and December 2008, a 10-year study of the observational database of the Irish prevention of mother-to-child transmission program that uses a 4- rather than 6-week neonatal ARV prophylaxis regimen was undertaken. Maternal and infant data were analyzed to determine the vertical transmission rate (VTR) and infant outcome. Infants were categorized as uninfected if, off ARVs, they had 2 negative human immunodeficiency virus (HIV) polymerase chain reaction (PCR) tests, the second at 3 months of age or older.

RESULTS

Between January 1999 and December 2008, there were 964 HIV-exposed live births. Excluding 7 early neonatal deaths, 4 weeks of ARV prophylaxis was prescribed for 957 infants: 61% received mono, 32% triple, and 7% dual therapy. Of 957 infants, 906 were uninfected, 10 infected, and 41 of indeterminate status. Twenty-four of the indeterminate status infants had at least one negative HIV PCR test at ≥ 6 weeks and 17 were lost to follow-up before 6 weeks of age. On the basis of 916 infants of known outcome, the VTR was 1.09% (95% confidence interval, 1.07-1.11). If restricted to 910 infants whose mothers received at least 4 weeks of antiretroviral therapy (ART), the VTR was 0.4%.

CONCLUSIONS

This study provides evidence to support the current clinical practice toward use of a 4-week neonatal ARV prophylaxis regimen.

Physicians' and patients' adherence to antiretroviral prophylaxis after sexual exposure to HIV: results from South-Eastern France

French national guidelines for the management of HIV non-occupational post-exposure (nPEP) were issued in 1998 and updated in 2003. NPEP is available and free of charge in all emergency or AIDS care units of French hospitals. A regional survey was carried out to study physicians' adherence to national guidelines, and determinants of adherence to nPEP follow-up in individuals sexually exposed to HIV. The survey was based on retrospective data collection of all consultations for nPEP made in the three AIDS information centers in South-Eastern France (January 2001-December 2002). Information included personal data, type of exposure, and treatment at the first visit after exposure and during follow-up. Exposures were classified into high risk (treatment highly recommended), moderate risk (treatment possibly recommended) and negligible risk (treatment never recommended) categories, according to the level of HIV risk of sexual transmission as indicated by the French national nPEP guidelines. Among the 910 sexual exposures, 56%, 37%, and 4% were classified as cases with high, moderate, and no risk respectively. NPEP was prescribed to 85% of cases. HIV risk of sexual exposure was significantly associated with nPEP receipt though more than half of the cases with negligible risk received nPEP. Independent characteristics associated with non-adherence to nPEP follow-up were younger age, being referred to hospital by a physician, sexual exposure with a casual partner or sexual assault, and "moderate risk" exposure. Better information should be provided to physicians prescribing nPEP to limit over-prescription while new strategies should be implemented to improve follow-up of individuals receiving nPEP, especially those who are younger or survivors of sexual assault.

The public health impact of widespread availability of nonoccupational postexposure prophylaxis against HIV

OBJECTIVE

The aim of the study was to describe the use of nonoccupational postexposure prophylaxis (NPEP) in Australia, and to estimate the number of HIV infections that its use prevented.

METHODS

We conducted a population-based observational cohort study of people who presented to antiretroviral prescribers in Eastern Australia, and reported a high-risk nonoccupational exposure to HIV, in 1998-2004. Prescribers collected data at baseline, 4 weeks and 6 months. Data collected included details of HIV exposure, drug regimens and HIV serostatus.

RESULTS

The great majority of the 1601 participants were male (95%) and presented after male homosexual exposure (87%). Only 32% of exposures were to HIV-positive sources. Two antiretroviral drugs were prescribed after 48% of events, and three or more drugs after 52% of events. The median time to receipt of NPEP was 23 h. Side effects were reported by 66% of participants. No case of NPEP failure in an adherent individual was identified. It was estimated that 0.9-9.2 HIV infections had been prevented. This compared with a total of 1138 newly acquired HIV infections notified in the geographical area covered by the study.

CONCLUSIONS

In Australia, NPEP has been widely prescribed and is mainly targeted at high-risk exposures. Although there were no identified failures of NPEP, it is likely that only a small proportion of new HIV infections in the study area were prevented. NPEP may be a valuable preventive intervention for an individual, but it can only play a minor role in HIV prevention at the population level unless targeting can be further improved.

Surveillance of HIV exposure and postexposure prophylaxis among health care workers in Greece

OBJECTIVE

Many developed countries have implemented surveillance systems for monitoring occupational exposure to HIV. The aim of the present study was to analyze surveillance data on HIV postexposure prophylaxis (PEP) for health care workers (HCWs) in Greece.

DESIGN

All data reported to the Hellenic Centre for Disease Control and Prevention between January 1996 and June 2005 were analyzed. SAMPLE AND MEASUREMENT: 188 reported occupational exposures to HIV were analyzed, retrospectively.

RESULTS

Most exposures were in the physicians (37.8%), followed by the nursing personnel (18.6%). Nearly 38% of the HCWs were males and the predominant type of biological material involved in the exposure was blood (74.5%). Two drugs were used for PEP in 23.4% of the HCWs, and 3 drugs in 66.5% of the reported cases.

CONCLUSIONS

Greek guidelines provide guidance for treating HCWs after occupational exposure to HIV. In our study, antiretroviral treatment, a three-drug regimen in the majority of the cases, was prescribed after evaluation of specially appointed physicians. The surveillance system of occupational exposure to HIV in HCWs should be further developed and enhanced in order to monitor and evaluate the risk factors surrounding the incidents.

Cost-effectiveness of HIV post-exposure prophylaxis in France

OBJECTIVE

To assess the cost-effectiveness of HIV post-exposure prophylaxis (PEP) in France.

METHODS

We used a decision tree to evaluate, from a society's perspective, the cost of PEP per quality-adjusted life-year (QALY) saved. We used 1999-2003 PEP surveillance data and literature-derived data on per event transmission probabilities, PEP efficacy and quality of life with HIV. HIV prevalence and lifetime cost of HIV/AIDS management in the HAART era were derived from French studies. We assumed that mean life expectancy in full health was 65 years among uninfected individuals and that the mean survival time after HIV infection was 22.5 years. The costs of PEP drugs and follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects.

RESULTS

During 1999-2003, PEP was prescribed to 8958 individuals (heterosexual sex: 47.6%; homosexual sex: 28.4%; occupational exposure: 23.4%; drug injection: 0.6%); of those, 2143 were exposed to a known HIV-infected source. PEP was estimated to prevent 7.7 infections and saved 64.5 QALY at a net cost of euro 5.7 million, resulting in an overall cost-effectiveness ratio of euro 88,692 per QALY saved. PEP was cost saving for 4.4% of cases and cost effective (< euro 50,000 per QALY) in a further 11.3% of cases. In contrast, 72 and 52% of prescriptions had a cost-effectiveness ratio exceeding euro 200,000 and euro 2 millions, respectively, per QALY saved.

CONCLUSION

Overall, the French PEP programme is only moderately cost effective. PEP guidelines should be revised to target high-risk exposures better.

Access to HIV Prophylaxis for Survivors of Sexual Assault: The Tip of the Iceberg

Background

In France non-occupational post-exposure prophylaxis (nPEP) is recommended in case of sexual assault and can be prescribed, after risk evaluation, in emergency or AIDS care units.

Methods

A survey was carried out on retrospective data of individuals being consulted for nPEP in southeastern France.

Results

Of the 915 consultations for sexual exposures, 94 were sexual assaults concerning adults. Most were prescribed nPEP (91.5%), but half were lost to follow-up.

Conclusions

During the study period throughout the same region, 623 survivors reported sexual assault to the police. The comparison of these figures shows that the number of victims who have no access to medical consultation for nPEP may be alarmingly high and strongly suggests the urgency to develop strategies for guaranteeing prompt HIV medical assessment for victims of sexual assault and assure adherence to medical follow-up.

Protection of healthcare workers from bloodborne pathogens

PURPOSE OF REVIEW

For decades, healthcare workers have been known to be at risk from acquiring a variety of bloodborne pathogen infections as a result of occupational exposure. Primary prevention of exposures, as recommended by universal precautions guidelines, remains the cornerstone of protecting healthcare workers. Nonetheless, a substantial number of parenteral exposures continue to occur. Updated developments are summarized here, and recommendations for the protection of healthcare workers from bloodborne pathogens are provided.

RECENT FINDINGS

The predominant evidence suggests that total percutaneous injuries have decreased over the last decade. Thoughtful adherence to universal precautions remains the primary means of preventing occupational exposures and thus of reducing occupational risk of infection with bloodborne pathogens. A number of studies have provided additional evidence for the efficacy of safety devices in reducing specific subsets of injuries when combined with education and administrative interventions. Barriers to and positive predictors of universal precautions compliance have been identified. Postexposure prophylaxis remains the second line of defense; several authorities have now recommended three antiretroviral agents in this setting.

SUMMARY

In summary, almost two decades of experience with universal/standard precautions has resulted in a decrease in parenteral injuries, but much work remains to be done. Vaccines, effective infection control procedures, safer procedures, and safer devices will all be necessary, along with a better understanding of factors that influence healthcare worker behaviors that result in injury. In addition, a number of issues relating to the postexposure management of occupational exposures with bloodborne pathogens need to be better understood.

Post-exposure prophylaxis of HIV infection in healthcare workers: recommendations for the European setting

The European Commission funded a project for the standardisation of the management of occupational exposures to HIV/blood-borne infections and antiretroviral post-exposure prophylaxis (PEP) in Europe. Within this project, the following recommendations and rationale were formulated by experts representative of participating countries. Based on assessment of the exposure, material, and source characteristics, PEP should be started as soon as possible with any triple combination of antiretrovirals approved for the treatment of HIV-infected patients; initiation is discouraged after 72 hours Rapid HIV testing of the source could reduce inappropriate PEP. HIV testing should be performed at baseline, 4, 12, and 24 weeks, with additional clinical and laboratory monitoring of adverse reactions and potential toxicity at week 1 and 2. HIV resistance tests in the source and direct virus assays in the exposed HCW are not recommended routinely. These easy-to-use recommendations seek to maximise PEP effect while minimising its toxicity and inappropriate use.

Cost-effectiveness of HIV postexposure prophylaxis following sexual or injection drug exposure in 96 metropolitan areas in the United States

OBJECTIVES

To evaluate the cost-effectiveness of HIV postexposure prophylaxis (PEP) following sexual or injection-related exposures in 96 metropolitan statistical areas in the United States (MSA).

DESIGN

Empirical, model-based cost-effectiveness analysis.

METHODS

Epidemiological and population size estimates from the literature were combined with information about the distribution of exposure types, PEP completion rate, proportion of source partners known to be HIV infected, and PEP program costs obtained from a feasibility study of PEP in San Francisco to estimate the cost-effectiveness of hypothetical PEP programs in each of the 96 MSA. The effectiveness of combination antiretroviral therapy following sexual or drug use-related exposures, which is presently not known, was assumed equal to the effectiveness of zidovudine monotherapy in the occupational setting. The main outcome measure was the cost-utility ratio, defined as the cost per quality-adjusted life year (QALY) saved by the PEP intervention.

RESULTS

The cost-utility ratios for the 96 MSA ranged from 4137 dollars to 39,101 dollars per QALY saved; only two of the ratios exceeded 30,000 dollars per QALY saved. Combined across the 96 MSA, the hypothetical PEP programs would reach nearly 20,000 clients at a total cost of approximately 22 million dollars. The overall cost-utility ratio across MSA was 12,567 dollars per QALY saved. The majority of the HIV infections prevented by PEP were among men and women who reported receptive anal intercourse exposure.

CONCLUSIONS

PEP following sexual or drug use-related exposures could be a cost-effective complement to existing HIV-prevention efforts in most MSA across the United States.

Two drugs or three? Balancing efficacy, toxicity, and resistance in postexposure prophylaxis for occupational exposure to HIV

Thousands of health care workers are potentially exposed to human immunodeficiency virus (HIV) each year via occupationally acquired needlesticks. The Centers for Disease Control and Prevention (Atlanta, GA) advise health care workers who experience a high-risk occupational exposure from an HIV-infected patient to begin receiving multidrug antiretroviral postexposure prophylaxis (PEP) as soon as possible, preferably within 36 h after exposure. Although the need to prescribe antiretroviral postexposure prophylaxis in a timely fashion is common, few data exist regarding the efficacy and optimal regimen for prophylaxis to prevent transmission. Our objectives were to examine the limited human and animal data on postexposure prophylaxis, to elucidate the factors that affect the choice of 2 versus 3 drugs as the optimal prophylactic drug regimen, and to place these findings within a mathematical framework to help guide the prescription of PEP.

Development of guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island

The Brown University AIDS Program and the Rhode Island Department of Health joined with health care practitioners, researchers, and representatives of community-based health, social service, and advocacy organizations to create comprehensive guidelines on nonoccupational HIV postexposure prophylaxis for the state of Rhode Island. These guidelines offer health care practitioners detailed advice on the evaluation and management of blood or body fluid exposures outside the health care setting, e.g., through sexual assault, consensual sex, injecting-drug use, or needlestick injuries. In these circumstances, HIV postexposure prophylaxis serves those for whom primary prevention measures have failed or were impractical or impossible. The guidelines represent the end product of coordination among private and public, academic and nonacademic, clinician and layperson groups committed to decreasing the incidence of HIV infections in the state of Rhode Island. The guidelines serve as both a resource for health care practitioners and a means of educating them on this method of HIV prevention.

Prise en charge des accidents d'exposition au VIH d'origine professionnelle et sexuelle : état des lieux au centre hospitalo-universitaire de Toulouse

OBJECTIVE

This study had aim to describe the management of occupational and sexual HIV exposure in the Toulouse teaching hospital.

DESIGN

A prospective descriptive study was made of patients reporting with potential HIV exposure in Toulouse between 01/01/2000 and 12/31/2002.

RESULTS

Six hundred and ninety three cases were reported, 236 after occupational and, 457 after sexual exposure. The frequency of sexual exposures increased with time. 61.2% of patients received post-exposure treatment and no seroconversion was diagnosed during their follow-up. Eighty-four percent of treated patients received three anti-retroviral drugs, with a protease inhibitor in 57%. Treatment was more frequently prescribed in sexual exposures than in occupational ones. For occupational exposures, the median time between exposure and consultation was 4 h and was decreased by spontaneous bleeding but not affected by source patient serostatus or injury deepness. Treatment was more frequent when injury was deep, when there was spontaneously bleeding, and when the source patient serostatus was positive or unknown. For sexual exposures, the median time between exposure and consultation was significantly superior to 4 h. That was diminished by positive source person serostatus but not affected by the partner's gender, nature of intercourse, or rape. Treatment was more frequently prescribed in case of positive or unknown source person serostatus, rape and homosexual intercourse.

CONCLUSIONS

Given the delay before consultation for sexual exposures and out of delay treatment in occupational exposures, discussion with health professionals on implementing procedures and means seems mandatory.

Use of postexposure prophylaxis against HIV infection following sexual exposure does not lead to increases in high-risk behavior

BACKGROUND

The effectiveness of postexposure prophylaxis (PEP) following occupational exposure to HIV has prompted advocacy for PEP following sexual or drug-use exposures.

OBJECTIVE

To evaluate the concern that the availability of PEP for sexual or drug-use exposures might result in behavioral disinhibition.

DESIGN

Non-randomized trial of 397 adults with high-risk sexual or drug-use exposures within the prior 72 h.

INTERVENTIONS

Antiretroviral medication for 4 weeks and five counseling sessions.

MAIN OUTCOME MEASUREMENTS

Participants were followed for 12 months for repeat request for PEP and for changes compared with pre-enrollment in overall high-risk behavior and the acquisition of sexually transmitted diseases (STD) and HIV.

RESULTS

After 12 months following receipt of PEP, the majority of participants (83%) did not request a repeat course of PEP. At 12 months after exposure, 73% of participants reported a decrease compared with baseline in the number of times they had performed high-risk sexual acts; 13% reported no change, and 14% had an increase. Most participants (85%) had no change in the incidence of STD; 8.5% had a decrease and 6.8% an increase. Three homosexual men seroconverted for HIV (none associated with the presenting exposure) for a rate of 1.2/100 person-year, equivalent to rates in San Francisco among all homosexual men.

CONCLUSIONS

After receipt of PEP consisting of antiretroviral medication and behavioral counseling following a potential sexual exposure to HIV, most individuals do not increase high-risk behavior. Coupled with prior safety and feasibility data, this lack of behavioral disinhibition suggests that use of PEP should be routinely considered following high-risk sexual exposures.

[Non-occupational post-exposure HIV prophylaxis. Knowledge and practices among physicians and groups with risk behavior]

BACKGROUND AND OBJECTIVE

Although occupational post-exposure HIV prophylaxis is widely admitted and used, the non-occupational post-exposure prophylaxis (NONOPEP) is controversial. Prevention of mother-to-child HIV transmission, experimental studies in animal models and retrospective studies in health workers, along with biological plausibility, would justify the use of NONOPEP in certain circumstances. Our objectives were: 1) To review the existence of recommendations; 2) To describe the attitudes, knowledge and practices of the professionals involved in the attention of non-occupational exposures to HIV; 3) To describe the attitudes and knowledge on such a prophylaxis by people with risk behaviours (homosexual men and intravenous drug users (IDU)); and 4) To describe the NONOPEP-related responses of telephone services of public attention on AIDS.

SUBJECTS AND METHOD

Descriptive study by means of a survey of each defined target population between September 1999 and July 2000, using self-administered questionnaires and personal interviews. Structured and simulated interviews were used to survey the telephone services.

RESULTS

To date, no official recommendations exist. 84% (97/116) of consulted doctors have taken care of some of non-occupational accidental exposure to HIV over the last six months. 77% (75/97) have prescribed NONOPEP, and 76% of doctors prescribing NONOPEP (57/75) have used the 1998 CDC recommendations for occupational exposures. Most frequent observed cases were related to needle sticks in the street and preservative breakage. The assessment of certain risk factors and therapeutic performance in cases of intermediate risk showed discrepancies among doctors. 41% (103/252) among homosexuals and 2% (3/160) among IDU on treatment know the NONOPEP. 15% (15/98) and 98% (70/118) respectively would take less prevention to avoid HIV infection if they took the NONOPEP. It was mentioned the possibility of NONOPEP in 20% (12/59) of calls to the information telephone services on AIDS.

CONCLUSIONS

HIV risk accidents susceptible of NONOPEP are relatively frequent. Without forgetting the greater importance of primary prevention, it is advisable to reach and agreement on homogeneous recommendations. It is also advisable to draw up a surveillance system to evaluate the application and eventually the effectiveness of these recommendations.

Human immunodeficiency virus postexposure prophylaxis for adolescents and children

Children and adolescents are at risk for human immunodeficiency virus (HIV) infection. Transmission occurs through perinatal exposures, injecting drug use, consensual and nonconsensual sex, needle-stick and sharp injuries, and possibly some unusual contacts. Youth engaging in high-risk sexual activities are especially endangered. Half of the estimated worldwide 5.3 million new HIV infections occur in adolescents and young adults aged 15 to 24. Of 20 000 known new adult and adolescent cases in the United States, 25% involve 13- to 21-year-olds. More than 1.4 million children worldwide (aged 15 and younger) are believed to be infected, and >1640 new cases are diagnosed daily. Of the 432 000 people reported to be living with HIV or acquired immunodeficiency syndrome (AIDS) in the United States, 5575 are children under 13. HIV postexposure prophylaxis (PEP) is a form of secondary HIV prevention that may reduce the incidence of HIV infections. HIV PEP is commonly conceived of as 2 types: occupational and nonoccupational. Occupational HIV PEP is an accepted form of therapy for health care workers exposed to HIV through their jobs. A landmark study of healthcare workers concluded that occupational HIV PEP may be efficacious. Well-established US national guidelines for occupational HIV PEP exist for this at-risk population. Nonoccupational HIV PEP includes all other forms of HIV PEP, such as that given after sexual assault and consensual sex, injecting drug use, and needle-stick and sharp injuries in non-health care persons. Pediatric HIV PEP is typically the nonoccupational type. The efficacy of nonoccupational HIV PEP is unknown. The presumed efficacy is based on a collection of animal and human data concerning occupational, perinatal, and nonoccupational exposures to HIV. In contrast to occupational HIV PEP, there are no national US guidelines for nonoccupational HIV PEP, and few recommendations are available for its use for adolescents and children. Regardless of this absence, there is encouraging evidence supporting the value of HIV PEP in its various forms in pediatrics. Although unproven, the presumed mechanism for HIV PEP comes from animal and human work suggesting that shortly after an exposure to HIV, a window period exists during which the viral load is small enough to be controlled by the body's immune system. Antiretroviral medications given during this period may help to diminish or end viral replication, thereby reducing the viral inoculum to a more potentially manageable target for the host's defenses. HIV PEP is accepted practice in the perinatal setting and for health care workers with occupational injuries. The medical literature supports prescribing HIV PEP after community needle-stick and sharp injuries and after sexual assault from sources known or likely to be HIV-infected. HIV PEP after consensual unprotected intercourse between HIV sero-opposite partners has had growing use in the adult population, and can probably be utilized for children and adolescents. There is less documented experience and support for HIV PEP after consensual unprotected intercourse between partners of unknown HIV status, after prolonged or multiple episodes of sexual abuse from an assailant of unknown HIV status, after bites, and after the sharing of personal hygiene items or exposure to wounds of HIV-infected individuals. There are no formal guidelines for HIV PEP in adolescents and children. A few groups have commented on its provision in pediatrics, and some preliminary studies have been released. Our article provides a discussion of the data available on HIV transmission and HIV PEP in pediatrics. In our article, we propose an HIV PEP approach for adolescents and children. We recommend a stratified regimen, based on the work of Gerberding and Katz and other authors, that attempts to match seroconversion risk with an appropriate number of medications, while taking into account adverse side-effects and the amount of information that is typically available upon initial presentation. Twice daily regimens should be used when possible, and may improve compliance. HIV PEP should be administered within 1 hour of exposure. We strongly recommend that physicians trained in this form of therapy review the indications for HIV PEP within 72 hours of its provision. We advocate that due diligence in determining level of risk and appropriateness of drug selection be conducted as soon as possible after an exposure has occurred. When such information is not immediately available, we recommend the rapid treatment using the maximum level of care followed by careful investigation and reconsideration in follow-up or whenever possible. HIV PEP may be initiated provisionally after an exposure and then discontinued if the exposure source is confirmed to not be HIV-infected. In most cases, consultations with the experts in HIV care can occur after the rapid start of therapy. (ABSTRACT TRUNCATED)