Antiretroviral post-exposure prophylaxis (PEP) for occupational HIV exposure

Rates of New Human Immunodeficiency Virus (HIV) Diagnoses After Reported Sexually Transmitted Infection in Women in Louisiana, 2000-2015: Implications for HIV Prevention

BACKGROUND

Human immunodeficiency virus (HIV) prevention interventions for prevention interventions for women include screening, partner notification, promoting condoms, and preexposure prophylaxis (PrEP). Women's risk of acquiring HIV can help guide recommendations.

METHODS

We used data from Louisiana's sexually transmitted infection (STI) and HIV registries to study 13- to 59-year-old women following first diagnosis of syphilis, gonorrhea, or chlamydia during 2000-2015. We measured HIV rates reported subsequent to STI (through 2016). Rates for women without STI were estimated by subtracting women with STI from reported cases and from Census estimates for the population. PrEP cost was estimated as $11 000 per year, and effectiveness estimated as 100%.

RESULTS

STIs were syphilis (6574), gonorrhea (64 995), or chlamydia (140 034). These 211 603 women had 1 865 488 person-years of follow-up and 969 HIV diagnoses. Women with no STI had 5186 HIV diagnoses over 24 359 397 person-years. HIV rates diagnosis (per 100 000 person-years) were higher for women after syphilis (177.3), gonorrhea (73.2), or chlamydia (35.4) compared to women with no STI (22.4). Providing PrEP to all women diagnosed with syphilis or gonorrhea would cost $7 371 111 000 and could have prevented 546 HIV diagnoses. Limiting PrEP to 1 year after syphilis or gonorrhea diagnosis would cost $963 847 334, but only 143 HIV diagnoses were within 2 years after a syphilis or gonorrhea diagnosis.

CONCLUSIONS

Rates of HIV diagnosis were high after women had STI, but not high enough to make PrEP cost-effective for them. Most women diagnosed with HIV did not have previously reported STI.

Cross-sectional survey on occupational needle stick injuries amongst prehospital emergency medical service personnel in Johannesburg

INTRODUCTION

Prehospital personnel are exposed to challenging situations that place them at increased risk of sustaining a needle stick injury (NSI). Blood borne infections such as HIV and Hepatitis B or C may be transmitted from a NSI. Sub-Saharan Africa has the largest number of people living with HIV globally. There is no data pertaining to NSI among Emergency Medical Service (EMS) personnel in South Africa. This study aimed to investigate the cumulative incidence, knowledge, attitudes and practices pertaining to NSIs amongst a select group of prehospital personnel in Johannesburg.

METHODS

This was a prospective, questionnaire based, cross-sectional survey of personnel employed at three EMS service providers in Johannesburg.

RESULTS

Of the 240 subjects that participated in the study, there was a total of 93 NSIs amongst 63 (26.3%) subjects. Of these, 41 (65.1%) had sustained one previous NSI, 16 (25.4%) had two NSIs, 5 (7.9%) had three NSIs and one (1.6%) had five NSIs. Almost two-thirds (n = 60; 64.5%) of NSIs were sustained during intravenous line insertion. Most of the study subjects were male (n = 145, 60.4%), between the age of 25-29 years (n = 67, 27.9%), had a BLS qualification as the highest level of training (n = 89, 37.1%), had >10 years of EMS experience (n = 69; 28.8%) and were up to date with their Hepatitis B vaccination at the time of the study. HIV post exposure prophylaxis (PEP) was initiated in 82 (88.2%) out of the 93 NSI incidents. However, the recommended 28-day course of therapy was only completed in 68 (82.9%) out of the 82 cases where PEP was initiated.

CONCLUSION

Prehospital personnel are at risk of sustaining a NSI. There is a need to promote awareness with regards to the risks, preventive measures, awareness of PEP protocols and the timely initiation and completion of HIV PEP amongst EMS personnel in Johannesburg.

Protocol of a scoping review assessing injury rates and their determinants among healthcare workers in western countries

INTRODUCTION

Healthcare workers (HCWs) are exposed to various risk factors and risky behaviours that may seriously affect their health and ability to work. The aim of this protocol is to detail the steps to follow in order to carry out a scoping review to assess the prevalence/incidence of injuries among HCWs.

METHODS AND ANALYSIS

The study will be carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols guidelines. Studies will be selected according to the following criteria: P (HCWs), E (exposure to injuries), C (different types of exposure and different categories of HCWs) and O (prevalence/incidence and determinants of injuries). A time filter has been set (literature between 2000 and 2018) to enable updated, direct comparison between the findings and the epidemiological data available at national and local 'Istituto Nazionale per l'Assicurazione contro gli Infortuni sul Lavoro' (National Institute for Insurance Against Accidents at Work) centres in Italy. No language restriction will be applied.

ETHICS AND DISSEMINATION

Formal ethical approval is not required; primary data will not be collected, as they have already been published. The results will be disseminated through peer-reviewed publication(s), conference presentation(s) and the press.

The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President's Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR's mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners-the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls' HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.

Environmental fate and ecotoxicological effects of antiretrovirals: A current global status and future perspectives

The therapeutic efficacy of antiretroviral drugs as well as challenges and side effects against the human immunodeficiency virus is well documented and reviewed. Evidence is available in literature indication that antiretrovirals are only partially transformed and become completely excreted from the human body in their original form and/or as metabolites in urine and feces. The possibility of massive release of antiretrovirals through human excreta that enters surface water through surface runoff and wastewater treatment plant effluents is now of environmental concern because the public might be experiencing chronic exposure to antiretrovirals. The primary concern of this review is limited data concerning environmental fate and ecotoxicity of antiretrovirals and their metabolites. The review aims to provide a comprehensive insight into the evaluation of antiretrovirals in environmental samples. The objective is therefore to assess the extent of analysis of antiretrovirals in environmental samples and also look at strategies including instrumentation and predictive models that have been reported in literature on the fate and ecotoxicological effects due to presence of antiretrovirals in different environmental compartments. The review also looks at current challenges and offers possible areas of exploration that could help minimize the presence of antiretrovirals in the environment.

Infection prevention and control: Who is the judge, you or the guidelines?

OBJECTIVES

The aim of this study was to explore the attitudes and behaviours of registered nurses and their colleagues around the adoption of standard precautions in order to determine strategies to promote adherence.

DESIGN

A qualitative exploratory descriptive design used interviews and focus group to collect data.

SETTING

Registered nurses and registered midwifes from a tertiary metropolitan hospital took part in the study.

PARTICIPANTS

A voluntary sample of 29 adults was recruited from the Australian nursing (n = 25) and midwifery (n = 4) workforce. There were six men (mean age = 36.83 years; SD = 8.93) and 23 women (mean age = 41.36 years; SD = 10.25). Participants were recruited through advertisement on notice boards and emails from unit managers.

RESULTS

Thematic analysis revealed five themes but the focus here is on staff judgements which are against the guidelines. Participants indicated that where in their judgement the patient posed no risk and they judged themselves skilled in the procedure, they were justified in deviating from the guidelines. Some staff judgements appeared to be self-protecting, while others were irrational and inconsistent.

CONCLUSIONS

Despite use of standard precautions being mandated, staff often deviated from them based on their own assessment of the situation or the patient. Any deviance from the guidelines is of concern but especially so when staff take it upon themselves to apply their own criteria or judgements. These results also suggest there may be some organisational inadequacies with regards to training and supervision of staff.

Pharmacokinetics of the Antiviral Lectin Griffithsin Administered by Different Routes Indicates Multiple Potential Uses

Griffithsin (GRFT) is a red alga-derived lectin with demonstrated broad spectrum antiviral activity against enveloped viruses, including severe acute respiratory syndrome-Coronavirus (SARS-CoV), Japanese encephalitis virus (JEV), hepatitis C virus (HCV), and herpes simplex virus-2 (HSV-2). However, its pharmacokinetic profile remains largely undefined. Here, Sprague Dawley rats were administered a single dose of GRFT at 10 or 20 mg/kg by intravenous, oral, and subcutaneous routes, respectively, and serum GRFT levels were measured at select time points. In addition, the potential for systemic accumulation after oral dosing was assessed in rats after 10 daily treatments with GRFT (20 or 40 mg/kg). We found that parenterally-administered GRFT in rats displayed a complex elimination profile, which varied according to administration routes. However, GRFT was not orally bioavailable, even after chronic treatment. Nonetheless, active GRFT capable of neutralizing HIV-Env pseudoviruses was detected in rat fecal extracts after chronic oral dosing. These findings support further evaluation of GRFT for pre-exposure prophylaxis against emerging epidemics for which specific therapeutics are not available, including systemic and enteric infections caused by susceptible enveloped viruses. In addition, GRFT should be considered for antiviral therapy and the prevention of rectal transmission of HIV-1 and other susceptible viruses.

Awareness About Needle Stick Injures and Sharps Disposal: A Study Conducted at Army College of Dental Sciences

BACKGROUND

The present study aims to assess the knowledge and attitude about needle stick injuries and sharps disposal.

METHODS

A self designed questionnaire of 15 questions was handed out to 200 participants including undergraduate students (group 1), postgraduate students (group 2), faculty members (group 3) and auxiliary staff members (group 4). The data was collected and analyzed using Chi square test.

RESULTS

Sixty-one percent of total participants reported of experiencing needle stick injury and 25.5 % knew that there could be several causes for this. Only 22 % of total population studied got the source tested. Immunization status of group 4 was very low and they also lacked the knowledge of sharps disposal and hepatitis C being spread by needle stick injuries. 57 % participants confirmed that there was no reporting facility and 66 % were not familiar with the guidelines of reporting.

CONCLUSIONS

There is a definite scope of improvement in terms of reporting and prevention of needle stick injuries. There is a need to improve knowledge and awareness of dental health care workers about the post exposure protocol.

Adverse events and adherence to HIV post-exposure prophylaxis: a cohort study at the Korle-Bu Teaching Hospital in Accra, Ghana

Background

There is strong evidence that post-exposure prophylaxis (PEP) with antiretroviral drugs in the timely management of occupational exposures sustained by healthcare workers decreases the risk of HIV infection and PEP is now widely used. Antiretroviral drugs have well documented toxicities and produce adverse events in patients living with HIV/AIDS. In the era of “highly active antiretroviral therapy”, non-adherence to treatment has been closely linked to the occurrence of adverse events in HIV patients and this ultimately influences treatment success but the influence of adverse events on adherence during PEP is less well studied.

Methods

Following the introduction of a HIV post-exposure prophylaxis program in the Korle-Bu Teaching Hospital in January 2005, the incidence of adverse events and adherence were documented in occupationally-exposed healthcare workers (HCWs) and healthcare students (HCSs). Cohort event monitoring was used in following-up on exposed HCWs/HCSs for the two study outcomes; adverse events and adherence. All adverse events reported were grouped by MedDRA system organ classification and then by preferred term according to prophylaxis regimen. Adherence was determined by the completion of prophylaxis schedule. Cox proportional regression analysis was applied to determine the factors associated with the cohort study outcomes. Differences in frequencies were tested using the Chi square test and p < 0.05 was considered statistically significant.

Results

A total of 228 exposed HCWs/HCSs were followed up during the study, made up of 101 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 3 days; 75 exposed HCWs/HCSs administered lamivudine/zidovudine (3TC/AZT) for 28 days; and 52 exposed HCWs/HCSs administered lamivudine/zidovudine/lopinavir-ritonavir (3TC/AZT/LPV-RTV) for 28 days. The frequency of adverse events was 28 % (n = 28) in exposed HCWs/HCSs administered 3TC/AZT for 3 days, 91 % (n = 68) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 96 % (n = 50) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. Nausea was the most commonly reported adverse events in all three regimens. Adherence was complete in all exposed HCWs/HCSs administered 3TC/AZT for 3days, 56 % (n = 42) in exposed HCWs/HCSs administered 3TC/AZT for 28 days and 62 % (n = 32) in exposed HCWs/HCSs administered 3TC/AZT/LPV-RTV for 28 days. In the Cox regression multi-variate analysis, exposed HCWs/HCSs administered 3TC/AZT for 3 days were 70 % less likely to report adverse events compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 0.30 [95 % CI, 0.18-0.48], p < 0.001). Exposed HCWs/HCSs administered 3TC/AZT for 3 days were 75 % more likely to adhere to the schedule compared with exposed HCWs/HCSs administered 3TC/AZT for 28 days (Adjusted HR = 1.75 [95 % CI, 1.16-2.66], p = 0.008).

Conclusion

The intolerance to adverse events was cited as the sole reason for truncating PEP, thereby indicating the need for adequate, appropriate and effective counselling, education, active follow-up (possibly through mobile /phone contact) and management of adverse events. Education on the need to complete PEP schedule (especially for exposed HCWs/HCSs on 28-day schedule) can lead to increased adherence, which is very critical in minimizing the risk of HIV sero-conversion. The present results also indicate that cohort event monitoring could be an effective pharmacovigilance tool in monitoring adverse events in exposed HCWs/HCSs on HIV post-exposure prophylaxis.

Risk for HIV following a diagnosis of syphilis, gonorrhoea or chlamydia: 328,456 women in Florida, 2000-2011

Several effective interventions are available for preventing HIV in women. Targeting interventions requires understanding their risk of acquiring HIV. We used surveillance data to estimate risks of HIV acquisition for 13-59-year-old women following a diagnosis of syphilis, gonorrhoea or chlamydia in Florida during 2000-2009. We excluded women reported with HIV before their STI, and measured HIV reported subsequent to STI (through 2011). Rates were compared to women with no reported STI. A total of 328,456 women had: syphilis (3325), gonorrhoea (67,784) or chlamydia (257,347). During 2,221,944 person-years of follow-up, 2118 of them were diagnosed with HIV. For women with no STI reported, during 64,763,832 person-years, 19,531 were reported with HIV. The crude rate of subsequent HIV diagnosis (per 100,000 person-years) was higher for women diagnosed with syphilis (597.9), gonorrhoea (171.3) or chlamydia (66.3) than women with no STI (30.2). Annual rates of HIV decreased over-all by 61.8% between 2001 and 2011. Women with syphilis or gonorrhoea were at highest risk for HIV and therefore might benefit from intensive counselling. However, they represented only a small fraction of the women who acquired HIV. Most cases of HIV infection among women occurred among the large group of women who were not at highest risk.

Cost-effectiveness of Methadone Maintenance Treatment in Prevention of HIV Among Drug Users in Shiraz, South of Iran

Background:

The increase in high-risk injections and unsafe sexual behaviors has led to increased HIV infection prevalence among Intravenous Drug Users (IDUs). The high costs of HIV/AIDS care and low financial resources necessitate an economic evaluation to make the best decision for the control of HIV/AIDS.

Objectives:

This study was conducted to determine the cost-effectiveness of Methadone Maintenance Treatment (MMT) centers in HIV infection prevention among drug users.

Materials and Methods:

In this interventional study, we included all the seven MMT centers and the drug users registered there (n = 694). We calculated all the costs imposed on the government, i.e. Provider of case. Mathematical models were used to estimate the number of HIV cases averted from high-risk behaviors. Sensitivity analyses were performed to show the effects of uncertainty in parameters on the number of HIV cases averted and also Incremental Cost-Effectiveness Ratio (ICER).

Results:

Based on the averted models, the selected MMT centers could prevent 128 HIV cases during 1 year. The total cost was $ 547423 and that of HIV/AIDS care in the no intervention scenario was estimated $ 14171816. ICER was $ 106382 per HIV case averted. The results of the sensitivity analysis indicated that MMT intervention was cost-effective even in the worst scenario and ICER varied from $ 39149 to $ 290004 per HIV case averted.

Conclusions:

With regard to the high prevalence of drug injection among drug users and considering the high effectiveness and cost-effectiveness of MMT centers in preventing HIV infection, establishment of MMT centers in regional and national levels seems reasonable.

HIV self-testing practices among Health Care Workers: feasibility and options for accelerating HIV testing services in Ethiopia

INTRODUCTION

HIV is still an enormous global burden and it is also causing loss of huge health care workers (HCWs) on the already limited human resource capacity in health care services in Sub-Saharan Africa. Variety of methods of accelerating HIV testing is required to increase the rate of HIV testing and expand treatment services. Therefore, this study was aimed to find out the prevalence, feasibility and options of HIV self-testing practices in Ethiopia.

METHODS

A cross-sectional study design triangulated with qualitative method was conducted from February to May, 2012. The data was collected using a semi-structured pretested questionnaire and in-depth interview, at government and private health centers or clinics and hospitals. During the data collection all the available healthcare workers (HCWs) which encompass the internship students including: Medical, Health Officer, Nurses, Midwives and Laboratory students, and health professionals working in the selected health institutions were involved.

RESULTS

A total of 307 HCWs were included in the analysis and we found that 288(94.4%) of them were ever tested for HIV, of which majority 203 (70.5%) were tested by themselves though 244(80%) of the HCWs had motivation or interest to be tested by themselves. Generally, of the ever tested only 85(29.5%) were tested by the help of health care providers/counselors other than self. Regarding the place where the HCWs had the test, majority 136 (69.4%) tested by themselves at the health facility and the rest were tested at their home, office, market and church. The main reason stated for self-testing was the need for confidentiality for the test result, which was mentioned by 205(82%). Moreover, 35(14.0%) claims lack of time to access the ordinary counseling and testing services.

CONCLUSION

This study depicts high rate of HIV self-testing practice among HCWs. This shows that HIV self-testing can be considered as one pillar to increase the HIV-testing services and a means for the HIV prevention and control policy, through increasing HIV testing uptake and awareness of HIV status. However, the implementation may require the role of different stakeholders and decision makers with further study to extend the options.

Telephone delivered interventions for preventing HIV infection in HIV-negative persons

BACKGROUND

This is one of the three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. Although HIV infection can be prevented, still a large number of new infections occur. More effective HIV prevention interventions are needed to reduce the number of people newly infected with HIV. Phone calls can be used to potentially more effectively deliver HIV prevention interventions. They have the potential to save time, reduce costs and facilitate easier access.

OBJECTIVES

To assess the effectiveness of voice landline and mobile telephone delivered HIV prevention interventions in HIV-negative persons.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, Web of Science, Cumulative Index to Nursing & Allied Health, the World Health Organization's Global Health Library and Current Controlled Trials from 1980 to June 2011. We searched the following grey literature sources: Dissertation Abstracts International and the Centre for Agricultural Bioscience International Direct Global Health database, the System for Information on Grey Literature Europe, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections database, International AIDS Society conference database, AIDS Education Global Information System and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series studies comparing the effectiveness of delivering HIV prevention by phone calls to usual care in HIV-negative people regardless of their demographic characteristics and in all settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched databases, screened citations, assessed study quality and extracted data. A third reviewer resolved any disagreement. Primary outcomes were knowledge about the causes and consequences of HIV/AIDS, change in behaviour, healthcare uptake and clinical outcomes. Secondary outcomes were users' and providers' views on the intervention, economic outcomes and adverse outcomes.

MAIN RESULTS

Out of 14,717 citations, only one study met the inclusion criteria. The included RCT recruited women and girl children who received post-exposure prophylaxis (PEP) after rape from sexual assault services in South Africa between August 2007 and May 2008.Participants (n (number) =274) were randomised into a telephone support (n=136) and control (n=138) group. Control group participants received usual care (an interactive information session) from the sexual assault service during the 28 days in which they had to take PEP, with no further contact from the study staff. Telephone support group participants received standard care and phone calls from a counsellor throughout the 28 days when they had to take PEP.Overall, adherence to PEP was not significantly (P=0.13) different between the intervention (38.2%) and control (31.9 %) groups. Also, the proportion of participants who read a pamphlet, did not return to collect medication or with a depression were not significantly different between the intervention and control groups (P=0.006, P=0.42, P=0.72 respectively). The proportion of participants who used a diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). The study authors reported that there were no recorded adverse events. The RCT did not provide information about participants' and providers' evaluation outcomes, or economic outcomes. The study had a moderate risk of bias.

AUTHORS' CONCLUSIONS

We found only one RCT, with a moderate risk of bias, which showed that providing PEP support by phone calls did not result in higher adherence to PEP. However, the RCT was conducted in an upper-middle-income country with high HIV prevalence, on a high-risk population and the applicability of its results on other settings and contexts is unclear. There is a need for robust evidence from various settings on the effectiveness of using phone calls for providing PEP support and for other HIV prevention interventions.

Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples

BACKGROUND

Antiretroviral drugs have been shown to reduce risk of mother-to-child transmission of human immunodeficiency virus (HIV) and are also widely used for post-exposure prophylaxis for parenteral and sexual exposures. Sexual transmission may be lower in couples in which one partner is infected with HIV and the other is not and the infected partner is on antiretroviral therapy (ART).

OBJECTIVES

To determine if ART use in an HIV-infected member of an HIV-discordant couple is associated with lower risk of HIV transmission to the uninfected partner compared to untreated discordant couples.

SEARCH METHODS

We used standard Cochrane methods to search electronic databases and conference proceedings with relevant search terms without limits to language.

SELECTION CRITERIA

Randomised controlled trials (RCT), cohort studies and case-control studies of HIV-discordant couples in which the HIV-infected member of the couple was being treated or not treated with ART DATA COLLECTION AND ANALYSIS: Abstracts of all trials identified by electronic or bibliographic scanning were examined independently by two authors. We initially identified 3,833 references and examined 87 in detail for study eligibility. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

One RCT and nine observational studies were included in the review. These ten studies identified 2,112 episodes of HIV transmission, 1,016 among treated couples and 1,096 among untreated couples. The rate ratio for the single randomised controlled trial was 0.04 [95% CI 0.00, 0.27]. All index partners in this study had CD4 cell counts at baseline of 350-550 cells/µL. Similarly, the summary rate ratio for the nine observational studies was 0.58 [95% CI 0.35, 0.96], with substantial heterogeneity (I(2)=64%). After excluding two studies with inadequate person-time data, we estimated a summary rate ratio of 0.36 [95% CI 0.17, 0.75] with substantial heterogeneity (I(2)=62%). We also performed subgroup analyses among the observational studies to see if the effect of ART on prevention of HIV differed by the index partner's CD4 cell count. Among couples in which the infected partner had ≥350 CD4 cells/µL, we estimated a rate ratio of 0.12 [95% CI 0.01, 1.99]. In this subgroup, there were 247 transmissions in untreated couples and 30 in treated couples.

AUTHORS' CONCLUSIONS

ART is a potent intervention for prevention of HIV in discordant couples in which the index partner has ≤550 CD4 cells/µL. A recent multicentre RCT confirms the suspected benefit seen in earlier observational studies and reported in more recent ones. Questions remain about durability of protection, the balance of benefits and adverse events associated with earlier therapy, long-term adherence and transmission of ART-resistant strains to partners. Resource limitations and implementation challenges must also be addressed.Counselling, support, and follow up, as well as mutual disclosure, may have a role in supporting adherence, so programmes should be designed with these components. In addition to ART provision, the operational aspects of delivering such programmes must be considered.

Managing drug resistance in cancer: lessons from HIV therapy

Drug resistance is a common cause of treatment failure for HIV infection and cancer. The high mutation rate of HIV leads to genetic heterogeneity among viral populations and provides the seed from which drug-resistant clones emerge in response to therapy. Similarly, most cancers are characterized by extensive genetic, epigenetic, transcriptional and cellular diversity, and drug-resistant cancer cells outgrow their non-resistant peers in a process of somatic evolution. Patient-specific combination of antiviral drugs has emerged as a powerful approach for treating drug-resistant HIV infection, using genotype-based predictions to identify the best matched combination therapy among several hundred possible combinations of HIV drugs. In this Opinion article, we argue that HIV therapy provides a 'blueprint' for designing and validating patient-specific combination therapies in cancer.

[Consensus document of Gesida and Spanish Secretariat for the National Plan on AIDS (SPNS) regarding combined antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2012)]

This consensus document has been prepared by a panel consisting of members of the AIDS Study Group (Gesida) and the Spanish Secretariat for the National Plan on AIDS (SPNS) after reviewing the efficacy and safety results of clinical trials, cohort and pharmacokinetic studies published in medical journals, or presented in medical scientific meetings. Gesida has prepared an objective and structured method to prioritise combined antiretroviral treatment (cART) in naïve patients. Recommendations strength (A, B, C) and the evidence which supports them (I, II, III) are based on a modification of the Infectious Diseases Society of America criteria. The current antiretroviral treatment (ART) of choice for chronic HIV infection is the combination of three drugs. ART is recommended in patients with symptomatic HIV infection, in pregnancy, in serodiscordant couples with high transmission risk, hepatitis B fulfilling treatment criteria, and HIV nephropathy. Guidelines on ART treatment in patients with concurrent diagnosis of HIV infection and an opportunistic type C infection are included. In asymptomatic patients ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts <350 cells/μL; 2) when CD4 counts are between 350 and 500 cells/μL, therapy will be recommended and only delayed if patient is reluctant to take it, the CD4 are stabilised, and the plasma viral load is low; 3) therapy could be deferred when CD4 counts are above 500 cells/μL, but should be considered in cases of cirrhosis, chronic hepatitis C, high cardiovascular risk, plasma viral load >10(5) copies/mL, proportion of CD4 cells <14%, and in people aged >55 years. ART should include 2 reverse transcriptase inhibitors nucleoside analogues and a third drug (non-analogue reverse transcriptase inhibitor, ritonavir boosted protease inhibitor or integrase inhibitor). The panel has consensually selected and given priority to using the Gesida score for some drug combinations, some of them co-formulated. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures, but an undetectable viral load may be possible nowadays. Adverse events are a fading problem of ART. Guidelines in acute HIV infection, in women, in pregnancy, and to prevent mother-to-child transmission and pre- and post-exposition prophylaxis are commented upon. Management of hepatitis B or C co-infection, other co-morbidities, and the characteristics of ART in HIV-2 infection are included.

Beyond the distinction between biomedical and social dimensions of HIV prevention through the lens of a social public health

Developing effective HIV prevention requires that we move beyond the historical but problematic distinction between biomedical and social dimensions of HIV. The current claim that prevention has failed has led to a strong interest in the role of treatment as HIV prevention; however, the turn to "biomedical prevention," "test and treat," and "combination prevention" instances pervasive confusions about prevention. These confusions arise from a failure to realize that all HIV prevention interventions must engage with the everyday lives of people and be integrated into their social relations and social practices. We challenge the claim that prevention has failed (illustrating this with discussion of prevention in Australia, Uganda, and Zimbabwe). We explain the enduring appeal of misguided approaches to prevention by examining how 1996 can be seen as a pivotal moment in the history of the global response to HIV, a moment marked by the rise and fall of distinct biomedical and social narratives of HIV.

A drug evaluation of 1% tenofovir gel and tenofovir disoproxil fumarate tablets for the prevention of HIV infection

INTRODUCTION

More than a million people acquire HIV infection annually. Pre-exposure prophylaxis (PrEP) using antiretrovirals is currently being investigated for HIV prevention. Oral and topical formulations of tenofovir have undergone preclinical and clinical testing to assess acceptability, safety and effectiveness in preventing HIV infection.

AREAS COVERED

The tenofovir drug development pathway from compound discovery, preclinical animal model testing and human testing were reviewed for safety, tolerability and efficacy. Tenofovir is well tolerated and safe when used both systemically or applied topically for HIV prevention. High drug concentrations at the site of HIV transmission and concomitant low systemic drug concentrations are achieved with vaginal application. Coitally applied gel may be the favored prevention option for women compared with the tablets, which may be more suitable for prevention in men and sero-discordant couples. However, recent contradictory effectiveness outcomes in women need to be better understood.

EXPERT OPINION

Emerging evidence has brought new hope that antiretrovirals can potentially change the course of the HIV epidemic when used as early treatment for prevention, as topical or oral PrEP. Although some trial results appear conflicting, behavioral factors, adherence to dosing and pharmacokinetic properties of the different tenofovir formulations and dosing approaches offer plausible explanations for most of the variations in effectiveness observed in different trials.

Lack of risk-awareness and reporting behavior towards HIV infection through needlestick injury among European medical students

Medical students are at risk for occupational needlestick injuries (NSIs) which can result in substantial health consequences and psychological stress. Therefore, an open online survey among final year medical students from Austria, Germany, and the United Kingdom (UK) was conducted. The aim of the study was to evaluate risk-awareness and reporting behavior regarding needlestick injury (NSI), post-exposure prophylaxis, and level of education regarding the transmission of HIV through NSIs. Of 674 medical students, 226 (34%) reported at least one NSI during medical school. Respondents from Austria and Germany experienced a significantly higher number of NSIs in comparison to respondents from the UK. Seventy-six respondents (34%) did not report their most recent injury to an employee health office. Almost one third were not familiar with reporting procedures in case of a NSI and 45% of the study population feared that reporting an injury might have an adverse effect on their study success. 176 respondents (78%) who had suffered a NSI were not aware of the patient's HIV status. Education regarding NSIs and HIV transmission reduced the actual risk of experiencing a NSI significantly. These data indicate that medical students are at high risk of suffering NSIs during medical school. The rate of nonreporting of such injuries to an employee health service is alarmingly high. Improved medical curricula including precise recommendations may contribute to a more efficient prevention of occupational HIV infection in medical students.

Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples

BACKGROUND

Antiretroviral drugs have been shown to reduce risk of mother-to-child transmission of human immunodeficiency virus (HIV) and are also widely used for post-exposure prophylaxis for parenteral and sexual exposures. Observational data, ecological studies and models suggest that sexual transmission may be lower in couples in which one partner is infected with HIV and the other is not and the infected partner is on antiretroviral therapy (ART).

OBJECTIVES

To determine if ART use in an HIV-infected member of an HIV-discordant couple is associated with lower risk of HIV transmission to the uninfected partner compared to untreated discordant couples.

SEARCH STRATEGY

We used standard Cochrane methods to search electronic databases and conference proceedings with relevant search terms without limits to language.

SELECTION CRITERIA

Randomised controlled trials, cohort studies and case-control studies of HIV-discordant couples in which the HIV-infected member of the couple was being treated or not treated with ART DATA COLLECTION AND ANALYSIS: Abstracts of all trials identified by electronic or bibliographic scanning were examined independently by two authors. We initially identified 1814 references and examined 23 in detail for study eligibility. Data were abstracted independently using a standardised abstraction form.

MAIN RESULTS

Seven observational studies and no randomised controlled trials were included in the review. These seven studies identified 436 episodes of HIV transmisison, 71 among treated couples and 365 among untreated couples. The summary rate ratio for all seven studies was 0.34 [95% CI 0.13, 0.92], with substantial heterogeneity (I(2)=73%). After excluding two studies with inadequate person-time data, we found a summary rate ratio of 0.16 [95% CI 0.07, 0.35] with no noted heterogeneity (I(2)=0%). We also performed subgroup analyses to see if the effect of ART on prevention of HIV differed by the index partner's CD4 cell count. Among couples in which the infected partner had >350 CD4 cells/µL, we estimated a rate ratio of 0.02 [95% CI 0.00, 2.87]. In this subgroup, there were 61 transmissions in untreated couples and none in treated couples.

AUTHORS' CONCLUSIONS

ART appears to be a potent intervention for prevention of HIV in discordant couples. However, the most important question from a clinical standpoint is whether being in a serodiscordant sexual relationship and having >350 CD4 cells/µL should be an indication for ART. In our analysis, there were broad confidence intervals in this subgroup, overlapping the null hypothesis of no effect. There is currently one large randomised controlled trial in the field, whose results are scheduled to be ready in 2015. Significant questions remain about durability of protection, when to start treating an infected partner (for instance, at diagnosis or at a specific CD4 level) and transmission of ART-resistant strains to partners.

An overview of post exposure prophylaxis for HIV in health care personals: Gujarat scenario

Average risk of acquiring HIV infection after a percutaneous exposure to HIV infected blood is 0.3%. Post exposure prophylaxis (PEP) for HIV refers to a set of comprehensive services to prevent HIV infection in exposed individuals where the exposure can be occupational/ non occupational and a provision of short term (28 days) antiretroviral drugs are given depending on the risk assessment. It also includes counselling and relevant laboratory investigations after taking informed consent of the exposed person and source. PEP inhibits the replication of the initial inoculum of virus and thereby prevents establishment of chronic HIV infection, and is best effective when initiated within 2 hours but certainly within 72 hours. Present communication deals with the registry of 278 cases of PEP from Gujarat in terms of various determinants, their status and the outcome in terms of HIV sero positivity.

Challenges of a hidden epidemic: HIV prevention among women in the United States

HIV/AIDS trends in the United States depict a concentrated epidemic with hot spots that vary by location, poverty, race/ethnicity, and transmission mode. HIV/AIDS is a leading cause of death among US women of color; two-thirds of new infections among women occur in black women, despite the fact that black women account for just 14% of the US female population. The gravity of the HIV epidemic among US women is often not appreciated by those at risk and by the broader scientific community. We summarize the current epidemiology of HIV/AIDS among US women and discuss clinical, research, and public health intervention components that must be brought together in a cohesive plan to reduce new HIV infections in US women. Only by accelerating research and programmatic efforts will the hidden epidemic of HIV among US women emerge into the light and come under control.

Periconception pre-exposure prophylaxis to prevent HIV transmission: benefits, risks, and challenges to implementation

HIV-serodiscordant couples face complicated choices between fulfilling reproductive desire and risking HIV transmission to their partners and children. Sexual HIV transmission can be dramatically reduced through artificial insemination and sperm washing; however, most couples cannot access these resources. We propose that periconception pre-exposure prophylaxis (PrEP) could offer an important, complementary therapy to harm reduction counseling programs that aim to decrease HIV transmission for couples who choose to conceive. In this paper, we describe the potential benefits of periconception PrEP and define critical points of clarification prior to implementation of PrEP as part of a reproductive health program. We consider sexual transmission risk, current risk reduction options, PrEP efficacy, cost, adherence, resistance, fetal toxicity, and impact of PrEP counseling on entry into health services. We address PrEP in the context of other periconception HIV-prevention strategies, including antiretroviral treatment of the HIV-infected partner. We conclude that, should PrEP prove safe and efficacious in ongoing trials, periconception PrEP may offer a useful approach to minimize risk of HIV transmission for individuals of reproductive age in HIV-endemic countries.

Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed

HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale.

Reviewing the evidence on effectiveness and cost-effectiveness of HIV prevention strategies in Thailand

Background

Following universal access to antiretroviral therapy in Thailand, evidence from National AIDS Spending Assessment indicates a decreasing proportion of expenditure on prevention interventions. To prompt policymakers to revitalize HIV prevention, this study identifies a comprehensive list of HIV/AIDs preventive interventions that are likely to be effective and cost-effective in Thailand.

Methods

A systematic review of the national and international literature on HIV prevention strategies from 1997 to 2008 was undertaken. The outcomes used to consider the effectiveness of HIV prevention interventions were changes in HIV risk behaviour and HIV incidence. Economic evaluations that presented their results in terms of cost per HIV infection averted or cost per quality-adjusted life year (QALY) gained were also included. All studies were assessed against quality criteria.

Results

The findings demonstrated that school based-sex education plus life-skill programs, voluntary and routine HIV counselling and testing, male condoms, street outreach programs, needle and syringe programs, programs for the prevention of mother-to-child HIV transmission, male circumcision, screening blood products and donated organs for HIV, and increased alcohol tax were all effective in reducing HIV infection among target populations in a cost-effective manner.

Conclusion

We found very limited local evidence regarding the effectiveness of HIV interventions amongst specific high risk populations. This underlines the urgent need to prioritise health research resources to assess the effectiveness and cost-effectiveness of HIV interventions aimed at reducing HIV infection among high risk groups in Thailand.

HIV-1 infection of a nurse from a newborn with an unknown HIV infection: a case report

BACKGROUND

HIV infection of healthcare workers by injury is an important issue in the management and prophylaxis of HIV-related disease.

OBJECTIVES

To describe a case where a nurse has been HIV-1 infected by needle-stick whilst taking blood from a newborn with an unknown HIV infection.

STUDY DESIGN

Virological, immunological and clinical analysis of a peculiar case of HIV transmission from newborn to nurse has been reported.

RESULTS

The nurse has been infected by needle-stick injury whilst taking blood from a newborn with an unknown HIV infection. The delayed declaration of accident by nurse and the inaccurate medical management of pregnant woman determined the subsequent absence of correct prophylaxis measures and then the impossibility to tackle the HIV transmission.

CONCLUSION

This case indicates that HIV serological screening of pregnant women and prompt accident notification by health-care workers represent basic preventive measures that should effectively tackle the spread of HIV infection.

Presentation of child sexual abuse cases to Queen Elizabeth Central Hospital following the establishment of an HIV post-exposure prophylaxis programme

AIM

To review the presentation and management of child sexual abuse cases presenting to Queen Elizabeth Central Hospital (QECH), Blantyre, since the introduction of an HIV postexposure prophylaxis programme.

METHODS

Demographic and medical data was collected from all children presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi between January 2005 and February 2007 with alleged child sexual abuse (CSA).

RESULTS

Between January 2005 and February 2007, 217 children presented with alleged CSA. This an average of 3 more per month since the previous year, a 57 percent increase. Physical examination showed signs of trauma 60% (130/217) of cases. 63% (137/217) of the cases presented within 72 hours of defilement. Overall in 42% (92/217) of children a one month course of HIV PEP was indicated and given. In 58% (125/217) HIV PEP was not indicated in view of normal examination, presentation too late (>72 hrs after abuse), multiple abuse episodes in the last 6 months, HIV test positive or HIV test refused. In 66% (144/217) of assessed children antibiotic treatment was given for the prevention and/ or treatment of sexually transmitted infections (STIs).

CONCLUSIONS

The introduction of an HIV PEP programme for victims of CSA has lead to increased numbers presenting and being treated. In conclusion it is likely that a significant number of children have been prevented from acquiring HIV and other STIs following CSA. The key area where our service needs to be improved is in establishing documented follow up of all cases to monitor medication compliance, side effects and rates of HIV seroconversion following CSA.

Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion

OBJECTIVES

Although anxiety exists concerning the perceived risk of transmission of bloodborne viruses after community-acquired needlestick injuries, seroconversion seems to be rare. The objectives of this study were to describe the epidemiology of pediatric community-acquired needlestick injuries and to estimate the risk of seroconversion for HIV, hepatitis B virus, and hepatitis C virus in these events.

METHODS

The study population included all of the children presenting with community-acquired needlestick injuries to the Montreal Children's Hospital between 1988 and 2006 and to Hôpital Sainte-Justine between 1995 and 2006. Data were collected prospectively at Hôpital Sainte-Justine from 2001 to 2006. All of the other data were reviewed retrospectively by using a standardized case report form.

RESULTS

A total of 274 patients were identified over a period of 19 years. Mean age was 7.9 +/- 3.4 years. A total of 176 (64.2%) were boys. Most injuries occurred in streets (29.2%) or parks (24.1%), and 64.6% of children purposely picked up the needle. Only 36 patients (13.1%) noted blood on the device. Among the 230 patients not known to be immune for hepatitis B virus, 189 (82.2%) received hepatitis B immunoglobulin, and 213 (92.6%) received hepatitis B virus vaccine. Prophylactic antiretroviral therapy was offered beginning in 1997. Of the 210 patients who presented thereafter, 82 (39.0%) received chemoprophylaxis, of whom 69 (84.1%) completed a 4-week course of therapy. The use of a protease inhibitor was not associated with a significantly higher risk of adverse effects or early discontinuation of therapy. At 6 months, 189 were tested for HIV, 167 for hepatitis B virus, and 159 for hepatitis C virus. There were no seroconversions.

CONCLUSIONS

We observed no seroconversions in 274 pediatric community-acquired needlestick injuries, thereby confirming that the risk of transmission of bloodborne viruses in these events is very low.

HIV-AIDS: urologic considerations

The prevalence of HIV continues to grow in the United States and worldwide. HIV-positive patients experience many genitourinary disease processes. With improvements in HIV therapy, patients have questions and concerns pertaining to their quality of life. This article reviews conditions such as HIV-related urinary tract infections, urolithiasis, voiding dysfunction, fertility, sexual dysfunction, HIV-related nephropathy, malignancies, and occupational exposure and prophylaxis. Knowledge of the various HIV manifestations of genitourinary conditions and their treatment options benefits clinicians and improves patient outcomes.

Human immunodeficiency virus postexposure prophylaxis for occupational exposure in a medical school hospital in Thailand

This is a retrospective review of occupational exposure to human immunodeficiency virus (HIV) and subsequent postexposure prophylaxis (PEP) among healthcare workers (HCWs) in King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. From January 2002 to December 2004, data were collected from incident reports, the hospital's infectious diseases unit and the emergency department. There were 315 reported episodes of occupational exposure among 306 HCWs. Nurses (34.0%) were the HCWs most frequently exposed and percutaneous injury (91.4%) was the most common type of exposure. One-third of the source patients tested were infected with HIV. PEP was initiated following 200 (63.5%) of the 315 exposures and was started within 24h in >95% of cases. The most commonly prescribed PEP regimen was zidovudine, lamivudine and nelfinavir. Fifty-six percent of HCWs given PEP completed a four-week course but the remainder discontinued PEP prematurely due to side-effects, or after negative results from the source, or following informed risk reassessment or from their own accord. No exposed HCW acquired HIV during the study period. Appropriate counselling and careful risk assessment are important in achieving effective HIV PEP among HCWs.

Preventing needlestick injuries

Inadvertent puncture during use, disassembly, or disposal of needles or sharp devices (called collectively, "sharps") creates risk beyond a simple puncture. Sharps injury has always been a risk for health care workers, but emergence of certain blood-borne pathogens has intensified the need to act. Three- hepatitis B, hepatitis C, and HIV-are of utmost concern because they can cause significant morbidity or death. The incidence of sharps injury remains unacceptably high. Injury analysis at long-term care facilities and at the national level reveals several trends that can be used to shape policy and select interventions. Policy, practice, and training need to address new devices engineered to prevent sharps injuries, sharps disposal containers, and prophylaxis after percutaneous injury.

Tenofovir disoproxil fumarate for prevention of HIV infection in women: a phase 2, double-blind, randomized, placebo-controlled trial

OBJECTIVES

The objective of this trial was to investigate the safety and preliminary effectiveness of a daily dose of 300 mg of tenofovir disoproxil fumarate (TDF) versus placebo in preventing HIV infection in women.

DESIGN

This was a phase 2, randomized, double-blind, placebo-controlled trial.

SETTING

The study was conducted between June 2004 and March 2006 in Tema, Ghana; Douala, Cameroon; and Ibadan, Nigeria.

PARTICIPANTS

We enrolled 936 HIV-negative women at high risk of HIV infection into this study.

INTERVENTION

Participants were randomized 1:1 to once daily use of 300 mg of TDF or placebo.

OUTCOME MEASURES

The primary safety endpoints were grade 2 or higher serum creatinine elevations (>2.0 mg/dl) for renal function, grade 3 or 4 aspartate aminotransferase or alanine aminotransferase elevations (>170 U/l) for hepatic function, and grade 3 or 4 phosphorus abnormalities (<1.5 mg/dl). The effectiveness endpoint was infection with HIV-1 or HIV-2.

RESULTS

Study participants contributed 428 person-years of laboratory testing to the primary safety analysis. No significant differences emerged between treatment groups in clinical or laboratory safety outcomes. Study participants contributed 476 person-years of HIV testing to the primary effectiveness analysis, during which time eight seroconversions occurred. Two were diagnosed in participants randomized to TDF (0.86 per 100 person-years) and six in participants receiving placebo (2.48 per 100 person-years), yielding a rate ratio of 0.35 (95% confidence interval = 0.03-1.93), which did not achieve statistical significance. Owing to premature closures of the Cameroon and Nigeria study sites, the planned person-years of follow-up and study power could not be achieved.

CONCLUSION

Daily oral use of TDF in HIV-uninfected women was not associated with increased clinical or laboratory adverse events. Effectiveness could not be conclusively evaluated because of the small number of HIV infections observed during the study.