Principles of clinical pharmacology in postexposure prophylaxis

Post-exposure prophylaxis after non-occupational HIV exposure: impact of recommendations on physicians' experiences and attitudes

OBJECTIVE(S)

To evaluate the impact of official recommendations for non-occupational HIV post-exposure prophylaxis (PEP), issued in France in 1998, on physicians' prescriptions and attitudes and the occurrence of severe PEP side-effects.

DESIGN

Two surveys were carried out among hospital physicians involved in HIV care, before (1997) and after (1999) the publication of recommendations.

METHODS

Questionnaires explored, for the last 12 months, description of PEP requests and prescriptions, detailed description of the latest treated exposure, prescription attitudes towards five exposure scenarios and types of severe side-effects of antiretroviral drugs (in 1999 only).

RESULTS

Nationally, from 1997 to 1999, PEP requests and prescriptions increased sevenfold and ninefold, respectively. Most requests followed sexual exposure (71% in 1997 and 86% in 1999; P = 10(-6)). The proportion of prescriptions for exposure to a known HIV-infected person decreased from 78% in 1997 to 41% in 1999 (P = 10(-6)). Three-drug combination therapies increased from 46% in 1997 to 83% in 1999 (P = 10(-6)). In 1999, 13 (0.9%; 95% confidence interval, 0.5-1.5%) severe reversible adverse events occurred among patients on a three-drug regimen. Prescription attitudes based mainly on risk assessment in 1997 (64% versus 33% in 1999) were based mainly on the request of the patient in 1999 (41% versus 11% in 1997).

CONCLUSION

Recommendations were followed by an increase of PEP, particularly after less risky exposures, and a substantial risk of severe side-effects. PEP should be restricted to well-documented exposures for which the risk of transmission outweighs the risk of severe side-effects. Drug regimens should be revised.