Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use

HIV non-occupational post-exposure prophylaxis (nPEP) awareness and promotion among five key populations in China: A cross-sectional study

Background

This study investigated HIV non-occupational post-exposure prophylaxis (nPEP) awareness and promotion, and related sociodemographic and behavioural factors among five key populations in China.

Methods

From November 2018 to September 2019, we adopted convenience sampling to recruit participants who were age ≥ 18, self-reported HIV status as either negative or unknown and provided informed consent from five key populations cross-sectionally in 10 Chinese cities. Univariable and multivariable logistic regressions were adopted.

Findings

Our analysis included data from 2022 participants with a mean age of 35 years (SD = 11·62). Approximately 60% of participants reported non-consistent condom use in the past month, and 37% had not been tested for HIV in the past 12 months. There were 857 (42%) participants hearing about nPEP before the study, and 1728 (86%) endorsing nPEP promotion after learning about nPEP. Sociodemographic and behavioural factors related to both nPEP awareness and endorsement of nPEP promotion included the key population indicator, age, HIV knowledge score, and HIV testing over life course.

Interpretation

The key populations in China generally had low nPEP awareness, particularly people who use drugs and female sex workers, while seronegative partners had the lowest endorsement of nPEP promotion. nPEP education and promotion campaigns should be integrated into conventional HIV services, and tailored to sexually active young individuals, people with poor HIV knowledge, and people never tested for HIV.

Funding

China National Key Research and Development Program and National Science and Technology Major Project, and the i Guardian Platform of the People's Medical Publishing House.

Mitochondrial Toxicogenomics for Antiretroviral Management: HIV Post-exposure Prophylaxis in Uninfected Patients

Background: Mitochondrial genome has been used across multiple fields in research, diagnosis, and toxicogenomics. Several compounds damage mitochondrial DNA (mtDNA), including biological and therapeutic agents like the human immunodeficiency virus (HIV) but also its antiretroviral treatment, leading to adverse clinical manifestations. HIV-infected and treated patients may show impaired mitochondrial and metabolic profile, but specific contribution of viral or treatment toxicity remains elusive. The evaluation of HIV consequences without treatment interference has been performed in naïve (non-treated) patients, but assessment of treatment toxicity without viral interference is usually restricted to in vitro assays.

Objective: The objective of the present study is to determine whether antiretroviral treatment without HIV interference can lead to mtDNA disturbances. We studied clinical, mitochondrial, and metabolic toxicity in non-infected healthy patients who received HIV post-exposure prophylaxis (PEP) to prevent further infection. We assessed two different PEP regimens according to their composition to ascertain if they were the cause of tolerability issues and derived toxicity.

Methods: We analyzed reasons for PEP discontinuation and main secondary effects of treatment withdrawal, mtDNA content from peripheral blood mononuclear cells and metabolic profile, before and after 28 days of PEP, in 23 patients classified depending on PEP composition: one protease inhibitor (PI) plus Zidovudine/Lamivudine (PI plus AZT + 3TC; n = 9) or PI plus Tenofovir/Emtricitabine (PI plus TDF + FTC; n = 14).

Results: Zidovudine-containing-regimens showed an increased risk for drug discontinuation (RR = 9.33; 95% CI = 1.34–65.23) due to adverse effects of medication related to gastrointestinal complications. In the absence of metabolic disturbances, 4-week PEP containing PI plus AZT + 3TC led to higher mitochondrial toxicity (−17.9 ± 25.8 decrease in mtDNA/nDNA levels) than PI plus TDF + FTC (which increased by 43.2 ± 24.3 units mtDNA/nDNA; p < 0.05 between groups). MtDNA changes showed a significant and negative correlation with baseline alanine transaminase levels (p < 0.05), suggesting that a proper hepatic function may protect from antiretroviral toxicity.

Conclusions: In absence of HIV infection, preventive short antiretroviral treatment can cause secondary effects responsible for treatment discontinuation and subclinical mitochondrial damage, especially pyrimidine analogs such as AZT, which still rank as the alternative option and first choice in certain cohorts for PEP. Forthcoming efforts should be focused on launching new strategies with safer clinical and mitotoxic profile.

Pediatric Considerations for Postexposure Human Immunodeficiency Virus Prophylaxis

Exposures that carry risk of transmission of blood-borne disease are rare in pediatrics, but expose patients and families to great anxiety. Specialists in pediatric infectious diseases are often asked about initial antimicrobial prophylaxis in these cases. Guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus have evolved as new formulations and medications become available and greater experience obtained in assessing relative risks of different exposures and relative costs and benefits for different interventions. This article discusses the evidence behind recent updates to Centers for Disease Control and Prevention guidelines for nonoccupational postexposure prophylaxis for human immunodeficiency virus, focusing on application in the pediatric population.

Addressing the dual health epidemics of HIV and sexual abuse among children and adolescents in Kenya: uptake of HIV counseling and post-exposure prophylaxis

Purpose

Child sexual abuse and HIV are key health challenges in Kenya. In 2015, LVCT Health conducted a study aimed at assessing the quality of HIV-related services offered to child survivors of sexual violence in public health facilities.

Materials and methods

A qualitative data collection approach was utilized. Qualitative data were collected through in-depth interviews with 31 providers. Quantitative methods included a retrospective review of 164 records of child survivors of rape who had accessed services 6 months prior to the commencement of the study. SPSS Version 22 was used in the descriptive analysis of the medical records. Client exit interviews and observation data were analyzed using MS Excel. In-depth interviews were analyzed using a thematic analytical approach.

Results

Twenty-seven percent (n=164) survivors were documented to have received the first dose of postexposure prophylaxis (PEP). Providers did not conduct HIV pre- and posttest counseling for the survivors. There were no longitudinal follow-up mechanisms to ensure child survivors initiated on PEP adhered to the treatment plan. Less than 30% of survivors returned to the facility for PEP adherence counseling and follow-up HIV testing. Twenty providers cited capacity gaps in undertaking HIV risk assessment for child survivors. Limited availability of PEP is a barrier to HIV prevention, as most departments only offer services between 8 am and 5 pm. HIV tests were only available on weekdays before 5 pm. PEP being out of stock remains a barrier to HIV prevention.

Conclusion

Existing post-rape care services are not adequately structured to facilitate delivery of quality HIV-related services to child survivors. Health provider capacity in the management of children remains weak due to lack of skill-based training on the dynamics of responding to the needs of child survivors. There is a need for standard operating procedures and training modules on the prevention of HIV in the context of child sexual abuse.

A Multi-US City Assessment of Awareness and Uptake of Pre-exposure Prophylaxis (PrEP) for HIV Prevention Among Black Men and Transgender Women Who Have Sex with Men

The HIV epidemic among Black men and transgender women who have sex with men (BMTW) demands an urgent public health response. HIV point prevalence among this population ranges from 25 to 43%-a rate far exceeding any other group. Pre-exposure prophylaxis (PrEP) for HIV prevention is a very promising prevention tool; however, its full potential to slow the epidemic has yet to be realized. For the current study, random time-location sampling at Black Gay Pride Events was used to collect data from N = 1274 BMTW, from five US cities, reporting HIV-negative/unknown status. In-field HIV testing was also provided to participants. Participants were assessed on awareness and use of PrEP, health care factors, HIV testing history, psychosocial variables, and sex behaviors. About one third of participants were aware of PrEP (39%), and a small percentage of participants were users of PrEP (4.6%). In multivariable analyses, being in a relationship, testing for HIV in the past 6 months, and others being aware of one's sexuality were positively associated with PrEP awareness. Higher levels of internalized homophobia and greater numbers of female sex partners were positively associated with PrEP use, while education and condom use were negatively associated. Based on study findings, messaging and uptake of PrEP needs greater expansion and requires novel approaches for scale-up. Improving linkage to HIV testing services is likely critical for engaging BMTW with PrEP. The potential for PrEP to slow the HIV epidemic is high; however, we must strengthen efforts to ensure universal availability and uptake.

Predictors of Standard Follow-Up Completion after Sexual Exposure to HIV: Five-Year Retrospective Analysis in a French HIV-Infection Care Center

Objectives

The care of exposed individuals to HIV remains a challenge regarding follow-up completion and HIV-testing of the partner. Identifying patients with risk of not fulfilling HIV-testing follow-up completion (FC), among patients demanding non-occupational post-exposure prophylaxis (nPEP), may improve clinical practice.

Methods

A retrospective chart review was conducted in a single French HIV-infection care center. FC predictors were assessed in a multivariate logistic regression model (Likelihood ratios test).

Results

Between 2009 and 2013, 646 sexual exposures to HIV were evaluated for nPEP, of which 507 effectively received nPEP (78%). FC rate was 30% (194/646). In the multivariate analysis, FC rates rose with age of exposed individuals (OR, 1.04 [0.25–4.28]; p<0.001) and decreased with the year of sexual exposure (OR, 0.74 [0.65–0.85]; p<0.001). FC was associated with sexual encounter with a sex worker (OR, 4.07 [0.98–16.82]; p<0.001) and nPEP use (OR, 2.69 [2.37–3.06]; p<0.001). nPEP early discontinuation was associated with decreased FC rates (OR, 0.18 [0.08–0.39]; p<0.001). No documented nPEP failure was identified. However, five Men who have Sex with Men (MSM) nPEP recipients for unprotected anal receptive intercourse subsequently seroconverted to HIV more than 6 months after nPEP. Seroconversion to HIV was associated with the lack of FC (p = 0.04) and multiple presentations for nPEP over the study period (p = 0.002).

Conclusions

We identified significant predictors of not fulfilling sequential HIV-testing. They appear to be linked with a self-perceived HIV risk, especially in young adults recently exposed. Enhanced counseling in targeted individuals with high risk behaviors and using smartphone and internet-based strategies may be interesting retention in care options.

Single-agent tenofovir versus combination emtricitabine plus tenofovir for pre-exposure prophylaxis for HIV-1 acquisition: an update of data from a randomised, double-blind, phase 3 trial

BACKGROUND

Antiretroviral pre-exposure prophylaxis (PrEP), with daily oral tenofovir disoproxil fumarate or tenofovir disoproxil fumarate in combination with emtricitabine, has been shown to be efficacious for HIV-1 prevention. Although the use of more than one antiretroviral agent is essential for effective HIV-1 treatment, more than one agent might not be required for effective prophylaxis. We assessed the efficacy of single-agent tenofovir disoproxil fumarate relative to combination emtricitabine plus tenofovir disoproxil fumarate as PrEP.

METHODS

We did a randomised, double-blind, placebo-controlled three-group phase 3 trial of daily oral tenofovir disoproxil fumarate and emtricitabine plus tenofovir disoproxil fumarate PrEP in HIV-1 uninfected individuals in heterosexual HIV-1 serodiscordant couples from Kenya and Uganda. After an interim review, the trial's placebo group was discontinued and thereafter the active groups were continued, and participants initially randomly assigned to placebo were offered rerandomisation in a 1:1 ratio to tenofovir disoproxil fumarate or emtricitabine plus tenofovir disoproxil fumarate as PrEP. The primary endpoints were HIV-1 seroconversion and safety. This trial is registered with ClinicalTrials.gov, number NCT00557245.

FINDINGS

4410 (99·6%) of 4427 couples received tenofovir disoproxil fumarate or emtricitabine plus tenofovir disoproxil fumarate and were followed up for HIV-1 acquisition. Of 52 incident HIV-1 infections, 31 occurred in individuals assigned tenofovir disoproxil fumarate (incidence 0·71 cases per 100 person-years) and 21 were in those assigned emtricitabine plus tenofovir disoproxil fumarate (0·48 cases per 100 person-years); HIV-1 incidence in the placebo group until discontinuation was two cases per 100 person-years. HIV-1 prevention efficacy with emtricitabine plus tenofovir disoproxil fumarate was not significantly different from that of tenofovir disoproxil fumarate alone (hazard ratio [HR] 0·67, 95% CI 0·39-1·17; p=0·16). Detection of tenofovir in plasma samples, compared with no detection and as measured in seroconverters and a subset of non-seroconverters, was associated with an 85% relative risk reduction in HIV-1 acquisition for the tenofovir disoproxil fumarate group (HR 0·15, 95% CI 0·06-0·37; p<0·0001) and 93% for the emtricitabine plus tenofovir disoproxil fumarate group (0·07, 0·02-0·23; p<0·0001). No significant differences were noted in the frequency of deaths, serious adverse events, or serum creatinine and phosphorus abnormalities between the two groups.

INTERPRETATION

These results do not rule out the potential for a slight difference in HIV-1 protection with tenofovir disoproxil fumarate compared with emtricitabine plus tenofovir disoproxil fumarate, but show that once-daily oral tenofovir disoproxil fumarate or emtricitabine plus tenofovir disoproxil fumarate regimens both provide high protection against HIV-1 acquisition in heterosexual men and women.

FUNDING

Bill & Melinda Gates Foundation and US National Institutes of Health.

Cost-effectiveness of interventions to prevent HIV and STDs among women: a randomized controlled trial

Injection drug use is a leading transmission route of HIV and STDs, and disease prevention among drug users is an important public health concern. This study assesses cost-effectiveness of behavioral interventions for reducing HIV and STDs infections among injection drug-using women. Cost-effectiveness analysis was conducted from societal and provider perspectives for randomized trial data and Bernoullian model estimates of infections averted for three increasingly intensive interventions: (1) NIDA's standard intervention (SI); (2) SI plus a well woman exam (WWE); and (3) SI, WWE, plus four educational sessions (4ES). Trial results indicate that 4ES was cost-effective relative to WWE, which was dominated by SI, for most diseases. Model estimates, however, suggest that WWE was cost-effective relative to SI and dominated 4ES for all diseases. Trial and model results agree that WWE is cost-effective relative to SI per hepatitis C infection averted ($109 308 for in trial, $6 016 in model) and per gonorrhea infection averted ($9 461 in trial, $14 044 in model). In sensitivity analysis, trial results are sensitive to 5 % change in WWE effectiveness relative to SI for hepatitis C and HIV. In the model, WWE remained cost-effective or cost-saving relative to SI for HIV prevention across a range of assumptions. WWE is cost-effective relative to SI for preventing hepatitis C and gonorrhea. WWE may have similar effects as the costlier 4ES.

Resilience as a research framework and as a cornerstone of prevention research for gay and bisexual men: theory and evidence

This commentary presents the content and results of a recent symposium held to discuss how resiliencies among gay and bisexual men, and other men who have sex with men, could inform HIV prevention interventions. We outline the argument for including resiliencies in prevention work and present a critique of the deficit-based approached to public health research as it applies to this line of inquiry. The commentary makes the case that HIV prevention work would be more efficacious if it were designed to incorporate naturally occurring resiliencies that manifest among gay male communities rather than primarily using interventions that address vulnerabilities among men who continue to reside in high risk contexts. The commentary concludes by listing a set of resiliency variables and constructs proposed at the meeting that could be tested in theoretically-based investigations to raise resiliencies among gay and bisexual men thereby lowering HIV risks in this population.

Condom distribution in jail to prevent HIV infection

To determine if a structural intervention of providing one condom a week to inmates in the Los Angeles County Men’s Central Jail MSM unit reduces HIV transmissions and net social cost, we estimated numbers of new HIV infections (1) when condoms are available; and (2) when they are not. Input data came from a 2007 survey of inmates, the literature and intervention program records. Base case estimates showed that condom distribution averted 1/4 of HIV transmissions. We predict .8 new infections monthly among 69 HIV-negative, sexually active inmates without condom distribution, but .6 new infections with condom availability. The discounted future medical costs averted due to fewer HIV transmissions exceed program costs, so condom distribution in jail reduces total costs. Cost savings were sensitive to the proportion of anal sex acts protected by condoms, thus allowing inmates more than one condom per week could potentially increase the program’s effectiveness.

Multicentre RCT and economic evaluation of a psychological intervention together with a leaflet to reduce risk behaviour amongst men who have sex with men (MSM) prescribed post-exposure prophylaxis for HIV following sexual exposure (PEPSE): a protocol

Background

Post-exposure prophylaxis (PEP) following sexual exposure to HIV has been recommended as a method of preventing HIV infection in the UK. Men who have sex with men (MSM) are the group most affected by HIV in the UK and their sexual risk taking behaviour is reported to be increasing. One-to-one behavioural interventions, such as motivational interviewing (MI) have been recommended to reduce HIV in high risk groups. The Information, Motivation and Behavioral skills (IMB) model has been shown to provide a good basis for understanding and predicting HIV-relevant health behaviour and health behaviour change, however the IMB has yet to be applied to PEP after risky sexual exposure. The primary aim of this trial is to examine the impact of MI augmented with information provision and behavioural skills building (informed by the IMB Model), over and above usual care, on risky sexual behaviour in MSM prescribed PEP after potential sexual exposure. A secondary aim of this research is to examine the impact of the intervention on adherence to PEP. This study will also provide estimates of the cost-effectiveness of the intervention.

Methods

A manualised parallel group randomised controlled trial with economic evaluation will be conducted. The primary outcome is the proportion of risky sexual practices. Secondary outcomes include: i) Levels of adherence to PEP treatment; ii) Number of subsequent courses of PEP; iii) Levels of motivation to avoid risky sexual behaviours; iv) Levels of HIV risk-reduction information/knowledge; v) Levels of risk reduction behavioural skills; vi) Diagnosis of anal gonorrhoea, Chlamydia and/or HIV. 250 participants will be asked to self-complete a questionnaire at four time points during the study (at 0,3,6,12 months). The intervention will consist of a two-session, fixed duration, telephone administered augmented MI intervention based on the IMB model. A newly developed treatment manual will guide the selection of persuasive communication strategies as appropriate for each participant and will be based on underlying change mechanisms specified by the IMB theoretical framework. Information provision and skills building will also be included in the intervention package through the use of information leaflets and tailored action plans. Fidelity of intervention delivery will be assessed.

Discussion

The results from this NIHR funded study will identify whether it is appropriate and cost-effective to intervene using one-to-one telephone calls with MSM seeking PEP. If the intervention is effective, further work will be needed on training staff to deliver the intervention competently.

Trial registration numbers

UKCRN ID:11436; ISRCTN00746242.

Timing of the medical examination

The medical examination of the sexually abused child may have evidentiary, medical, and therapeutic purposes, and the timing of the examination requires consideration of each of these objectives. In cases of acute sexual assault, emergent examinations may be needed to identify injury, collect forensic evidence, and provide infection and pregnancy prophylaxis. Alternately, most sexually abused children are not identified immediately after assault, and the timing of the examination needs to balance physical and emotional issues with the availability of qualified examiners. In all cases, the best interests of the child should be paramount.

[Prevention of HIV transmission (vertical, occupational and non-occupational)]

In these almost thirty years since the epidemic of HIV infection strategies have been developed to decrease the transmission risk when a non-infected person comes into contact with HIV. One of the key landmarks was the use zidovudine was shown to reduce the risk of HIV infection by vertical transmission from 25% to 8% when given from the second trimester of pregnancy, during partum and for several weeks in the newborn. These strategies have been subsequently perfected until achieving vertical transmission rates less than 1%. Almost at the same time, strategies have been developed in an attempt to reduce the risk of transmission of infection after occupational accidents and, in the last few years prophylaxis after non-occupational exposure has been a field of particular concern. Even in this past year several experiments on pre-exposure prophylaxis have been published, which are generating an intense debate on is applicability. In this article, we analyse the state of the art in the prevention of vertical transmission and occupational and non-occupational prophylaxis, from a perspective of applying this in the developed world. We also review the published data on pre-exposure prophylaxis.

Aggregate versus individual-level sexual behavior assessment: how much detail is needed to accurately estimate HIV/STI risk?

The sexual behaviors of HIV/sexually transmitted infection (STI) prevention intervention participants can be assessed on a partner-by-partner basis: in aggregate (i.e., total numbers of sex acts, collapsed across partners) or using a combination of these two methods (e.g., assessing five partners in detail and any remaining partners in aggregate). There is a natural trade-off between the level of sexual behavior detail and the precision of HIV/STI acquisition risk estimates. The results of this study indicate that relatively simple aggregate data collection techniques suffice to adequately estimate HIV risk. For highly infectious STIs, in contrast, accurate STI risk assessment requires more intensive partner-by-partner methods.

A forensic nursing protocol for initiating human immunodeficiency virus post-exposure prophylaxis following sexual assault

The use of human immunodeficiency virus post-exposure prophylaxis (HIV PEP) should be considered in the care of sexual assault patient populations. In order to effectively implement HIV PEP following sexual assault, healthcare providers need to have a working knowledge of HIV transmission risk factors following a sexual exposure and protocols for initiating HIV PEP. Being able to implement evidence-based practices that address each of these factors is paramount to successful prevention of HIV transmission following a sexual assault exposure. Most healthcare practitioners, however, lack the specialized knowledge needed to address these issues in the expeditious manner necessitated by a potential HIV exposure.

IMPLICATIONS

This paper is designed to provide healthcare providers with a basic understanding of HIV transmission risk factors and the knowledge and skills needed to effectively implement HIV PEP following a sexual assault exposure.

Sexual risk behaviors among men who have sex with men using erectile dysfunction medications

This study examined relationships between use of the phosphodiesterase type-5 (PDE-5) inhibitors (erectile dysfunction medications) sildenafil (Viagra), Pfizer, New York, NY), tadalafil (Cialis), Eli Lily, Indianapolis, IN), and/or vardenafil (Levitra), Bayer, Berlin, Germany), substance use, perceptions of risk, and sexual behavior in men who have sex with men (MSM). MSM (N = 342) attending a gay pride festival completed a brief survey assessing sexual behavior, risk perceptions, and substance use, including the use and the source of PDE-5 inhibitors. More than a quarter of the sample (26.3%, n = 89) reported having ever used a PDE-5 inhibitor. Those reporting use of PDE-5 inhibitors had higher rates of sexual risk behaviors and differed in their assessment of the risk of HIV transmission for unprotected anal sex. Users who received PDE-5 inhibitors from their doctors did not report sexual behaviors that differed significantly from those who received PDE-5 inhibitors from nonphysician sources. In a sequential logistic regression analysis, recent PDE-5 inhibitor use was associated with unprotected anal sex after accounting for the influence of age, education, ethnic identity, and substance use. Many MSM users of erectile dysfunction drugs report behaviors that may place their and others' health at risk. Interventions to reduce risk among MSM PDE-5 inhibitor users should be explored.

HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault

BACKGROUND

The appropriate use of antiretroviral medications to protect against infection with human immunodeficiency virus (HIV) is unclear in cases of sexual assault of children, for whom the perpetrator's risk of HIV is often unknown, and physical proof of sexual contact is usually absent.

OBJECTIVE

In an effort to clarify prescribing practices for HIV post-exposure prophylaxis (PEP) at our institution, we examined records of all children tested for HIV for prevalence of infection, our experience with prescribing PEP, and follow-up rates.

DESIGN/METHODS

Medical records at a sexual abuse clinic of all children tested for HIV during a 38-month period were reviewed for information concerning risk factors for HIV acquisition, STI test results, and PEP experience. Children were defined as PEP-eligible if they were within 96 hours of assault, and there was a report of sexual contact with the potential to transmit HIV.

RESULTS

One thousand seven hundred and fifty children were tested for HIV during the study period. Five children had a positive HIV ELISA, but only one child was confirmed HIV-positive. Three hundred and three children were eligible to receive HIV-PEP, but it was only offered to 16 (5.3%), of whom 15 accepted the medications. None of the children prescribed PEP completed follow-up, but 11 children had limited follow-up.

CONCLUSIONS

Our results indicate that the prevalence of HIV infection among sexually abused children in our population is low, and follow-up rates are poor. Intensive efforts to try to ensure follow-up are warranted whenever PEP is prescribed. Further research may help better define the efficacy of PEP in sexually abused children and adolescents.

When do simpler sexual behavior data collection techniques suffice? An analysis of consequent uncertainty in HIV acquisition risk estimates

The "gold standard" for evaluating human immunodeficiency virus (HIV) prevention programs is a partner-by-partner sexual behavior assessment that elicits information about each sex partner and the activities engaged in with that partner. When collection of detailed partner-by-partner data is not feasible, aggregate data (e.g., total numbers of partners and acts of various types) must suffice. Lack of specificity in the primary data often translates into uncertainty in modeled outcomes, such as participants' risk of HIV acquisition. To our knowledge, no previous study has attempted to quantify this uncertainty. The results of the present analysis of the risk of HIV acquisition by men vacationing in Key West indicate that the use of aggregate rather than partner-by-partner data introduced relatively little uncertainty into the HIV risk estimates. Collection of aggregate data is a viable alternative to detailed partner-by-partner data, at least in some circumstances.

Trends in HIV Postexposure Prophylaxis Prescription and Compliance After Sexual Exposure in Amsterdam, 2000–2004

OBJECTIVE

The objective of this study was to evaluate trends in HIV postexposure prophylaxis (PEP) requests after sexual exposure, compliance, and outcome of follow-up HIV tests.

STUDY DESIGN

The authors conducted a retrospective analysis of all HIV PEP requests after sexual exposure between January 1, 2000, and December 31, 2004, in Amsterdam.

RESULTS

In 5 years, there was a very modest increase in PEP requests, of which most (75%) came from men who have sex with men (MSM). Although 70% reported side effects, 85% completed their PEP course. Sexual assault victims less often completed their course (odds ratio [OR] = 0.1; 95% confidence interval [CI] = 0.05-0.4, P = 0.001). People who used HIV PEP more often complied with follow-up tests than people who did not use PEP (OR = 3.5; 95% CI = 1.6-7.9, P = 0.002). One HIV seroconversion was found caused by a later exposure than that for which PEP was given.

CONCLUSIONS

Despite a widely available PEP program in Amsterdam, the number of PEP requests remained low. Most people completed their PEP course; compliance with follow-up HIV testing was high.

Safe sex after post-exposure prophylaxis for HIV: Intentions, challenges and ambivalences in narratives of gay men

This paper draws on findings from an on-going prospective cohort study, with a quantitative and a qualitative arm, to monitor the implementation of non-occupational post-exposure prophylaxis (PEP) in Australia. The aim of the qualitative arm was to explore in-depth details of exposures to HIV and participants' understanding of 'risk'. Of the 328 patients who were enrolled in the study from March 1999 to July 2001, 88 (27%) participated in the qualitative arm. Interviews were conducted in a semi-structured style and explored the event that precipitated the request for PEP, participants' understanding of safe sex, their physical and psychological experience of the treatment and the impact that the availability of PEP may have on their sexual practices in the future. One theme running through the interviews was a determination to either maintain existing high levels of safe sex or to increase safe sex practices in those men who perceived PEP as 'a wake up call'. This determination was motivated by the experience of taking combination therapies and reflection on a potentially HIV-positive future. However, there were also tensions and ambivalences in the narratives. PEP was promoted as an adjunct to safe sex, not as an alternative. This is how PEP was understood by the men in this study.

Sexual risk and HIV acquisition among men who have sex with men travelers to Key West, Florida: a mathematical modeling analysis

The present study investigated the sexual risk behaviors of men who have sex with men (MSM) traveling to a popular gay tourist destination in the United States. In 2004, a brief survey was administered to 247 MSM tourists recruited from gay-oriented venues in Key West, Florida. Data collected included demographics, HIV status, length of stay, substance use, and sexual risk behaviors. A probabilistic model of HIV transmission was used to translate participants' reports of their sexual behaviors while in Key West into estimates of their risk of acquiring HIV. Twenty-two percent of participants reported anal sex with multiple partners over a relatively brief period (M = 4.1 days), and approximately one third reported having sex with a partner met during the vacation period. Modeling analyses suggested that sexual activity among vacationing MSM would account for approximately 201 new HIV infections among MSM visitors to Key West each year. Although previous studies have documented sexual risk behavior in travelers, quantitative estimates of the impact of these behaviors on the spread of HIV are lacking. Findings suggest that the risk-taking behavior of MSM on vacation may play an important role in the dissemination of HIV and other sexually transmitted diseases (STDs). Future research should assess additional factors (e.g., use of highly active antiretroviral therapy) that may affect HIV transmission in MSM travelers. In addition, efforts are needed to develop effective risk-reduction interventions for this population.

Factors Affecting Knowledge of Sexually Transmitted Infection Transmissibility in Healthcare Providers: Results From a National Survey

OBJECTIVES

The objectives of this study were to examine healthcare providers' knowledge of the transmissibility of sexually transmitted infections (STIs) and identify knowledge determinants.

STUDY

Questionnaires were completed March through May 2004 by a representative sample of Canadian healthcare providers, yielding a corrected response rate of 50.8% for physicians. STI workers returned 236 questionnaires.

RESULTS

For physicians, the distribution of HIV estimates was positively skewed (mode = 10%), whereas chlamydia estimates were widely dispersed. STI workers showed a trimodal (0%, 50%, and 100%) distribution of HIV estimates and a negatively skewed distribution of chlamydia estimates (mode = 100%). Overall, 1.4% (HIV) and 5.8% (chlamydia) of respondents gave estimates close to the actual transmission probabilities. More years of medical experience and higher estimates of STI prevalence predicted higher transmissibility estimates (95% confidence intervals).

CONCLUSIONS

That only a small percentage of healthcare providers are aware of the actual transmissibility of HIV and chlamydia has implications for improving medical and sexual health training.

Behavioral impact, acceptability, and HIV incidence among homosexual men with access to postexposure chemoprophylaxis for HIV

BACKGROUND

Little is known about the behavioral impact, acceptability, and incidence of HIV infection in persons with easy access to post-sexual exposure prophylaxis (PEP) to prevent HIV.

METHODS

Participants were recruited from a well-characterized, high-risk HIV seronegative homosexual male cohort in Rio de Janeiro, Brazil, given a 4-day supply of zidovudine and lamivudine, and instructed to begin PEP immediately after an eligible exposure. For eligible exposures, an additional 24-day supply was provided. Reported behavior, PEP utilization, adverse events, and incident HIV infection were the main study outcomes. The observed and expected incidences of HIV infection were compared.

RESULTS

Two hundred subjects were enrolled and followed for a median of 24.2 months. The median age was 28 years. PEP was initiated 109 times by 68 participants (34.0%). In comparison to reported behavior at baseline, reported high-risk sexual activities on average declined over time for both PEP and non-PEP users. There were no serious drug-related adverse events. There were 11 HIV seroconversions, 10 among non-PEP users and 1 that was a PEP failure. The overall seroincidence was 2.9 per 100 person-years (95% CI = 1.4, 5.1). The expected number of new HIV infections and corresponding expected seroincidence based on the risk profile were 11.8 and 3.1, respectively (P > 0.97). The most commonly reported reasons for not initiating PEP among seroconverters were sex with a steady partner and not considering the exposure to be of sufficiently high risk to warrant PEP.

CONCLUSION

PEP was safe and did not appear to be associated with increases in reported high-risk behavior in our cohort. Ready access to PEP did not appear to substantially affect HIV transmission, suggesting a limited public health impact of this intervention.

Human immunodeficiency virus postexposure prophylaxis in child and adolescent victims of sexual assault

OBJECTIVES

This study was performed at an urban children's hospital to identify the characteristics of patients given human immunodeficiency virus (HIV) postexposure prophylaxis and describe the adherence and associated side effects of HIV prophylaxis in child and adolescent victims of sexual abuse.

METHODS

A retrospective review of all children presenting for evaluation of suspected sexual abuse who were provided HIV prophylaxis between February 1999 and March 2001 was performed. Measured variables included risk factors for transmission of HIV, antiretrovirals prescribed and their side effects, initial and follow-up laboratory results, and compliance.

RESULTS

The medical records of 34 patients were examined. Assault by a stranger was the most common risk factor prompting prophylaxis. Zidovudine and lamivudine were prescribed for 32 patients (94%). Only 17 patients (50%) kept at least 1 follow-up appointment; 8 patients (24%) finished the entire course of prophylaxis. Side effects were reported in 11 (65%) of 17 patients, but only 1 patient was known to have stopped prophylaxis because of subjective side effects, and 1 patient was removed from prophylaxis due to laboratory abnormality.

CONCLUSIONS

Adherence to medication regimen and follow-up appointments in victims of suspected sexual abuse who are provided HIV prophylaxis is poor. The medications are associated with several side effects, but rarely do the side effects prohibit their use. Given difficulties with compliance, potential adverse effects of medications, and the high cost of treatment, care should be taken in offering prophylaxis to only those at increased risk for transmission of disease.

Cost-Effectiveness of a Community-Level HIV Risk Reduction Intervention for Women Living in Low-Income Housing Developments

We conducted a cost-effectiveness analysis of a multi-site community-level HIV prevention trial that enrolled women living in 18 low-income housing developments in 5 U.S. cities. A mathematical model of HIV transmission was used to estimate the number of HIV infections averted and quality-adjusted life years (QALYs) saved by the community-level intervention, based on data obtained from community-wide sexual behavior surveys at baseline and 12-month follow-up. Results indicated that the intervention prevented approximately 1 infection per 3500 women reached by the intervention, at a total cost of 174,845 dollars. The cost per QALY saved by the intervention was 37,433 dollars and the cost per HIV infection averted was 732,072 dollars. The community-level intervention was moderately cost-effective in comparison with other HIV prevention programs for at-risk women. Synergistic approaches to HIV prevention that combine community-level sexual norm change interventions with more intensive risk reduction programs for high-risk women are needed. EDITORS' STRATEGIC IMPLICATIONS: The authors present a promising and efficient community-level HIV prevention approach, with effects beyond the limited scope of individual or small group interventions. This paper represents an example of how an analysis of cost-effectiveness can provide policymakers with information needed for difficult decisions about prevention resource allocations.

Prophylaxis and follow-up after possible exposure to HIV, hepatitis B virus, and hepatitis C virus outside hospital: evaluation of policy 2000-3

PROBLEM

Prophylactic treatment and follow-up after exposure to HIV, hepatitis B, and hepatitis C outside hospital needs to be improved.

BACKGROUND AND SETTING

Until January 2000, people in Amsterdam could report exposure outside hospital to either a hospital or the municipal health service. If they reported to the municipal health service, they were then referred to hospitals for HIV prophylaxis, whereas the municipal health service handled treatment and follow-up related to hepatitis B and hepatitis C and traced sources. For cases reported to a hospital, hospital staff often did not trace HIV sources or follow up patients for hepatitis B and hepatitis C.

KEY MEASURES FOR IMPROVEMENT

Providing adequate treatment for HIV, hepatitis B and hepatitis C after exposure for all reported exposures outside hospital.

STRATEGIES FOR CHANGE

On 1 January 2000, a new protocol was introduced in which three Amsterdam hospitals and the municipal health service collaborated in the treatment and follow-up of exposures outside hospital. Both municipal health service and hospitals can decide whether HIV prophylaxis is necessary and prescribe accordingly. All people exposed in the community who report to hospitals are subsequently referred to the municipal health service for further treatment and follow-up.

EFFECTS OF CHANGE

The protocol is effective in that most people comply with treatment and follow-up. When indicated, HIV prophylaxis is started soon after exposure. In nearly two thirds of cases the municipal health service traced and tested the source.

LESSONS LEARNT

Provision of treatment and follow-up in one place enables treatment, tracing and testing sources, and follow-up, including counselling and registration of all reported exposures in Amsterdam, which allows for swift identification of emerging epidemiological trends. Since May 2004 all Amsterdam hospitals have participated in the protocol.

Incidence of Sexually Transmitted Diseases and HIV Infection Related to Perceived HIV/AIDS Threat Since Highly Active Antiretroviral Therapy Availability in Men Who Have Sex With Men

OBJECTIVE

Concerns have been expressed regarding increase in risky sex because of the availability of antiretroviral treatments in Western countries.

GOAL

The goal of this longitudinal study was to investigate the association between highly active antiretroviral therapy (HAART)- and postexposure prophylaxis-related beliefs and the incidence of sexually transmitted diseases (STDs) and new HIV infections in men who have sex with men (MSM).

STUDY

Data on the incidence of STDs and new HIV infection, and the level of agreement with different HAART- and PEP-related beliefs from 151 HIV-negative MSM were compiled.

RESULTS

Of all MSM, 65.6% tested negative for any STDs and 7 men HIV seroconverted. Perceiving less HIV/AIDS threat since HAART availability and younger age were significantly associated with a higher incidence of STDs. Perceiving less need for safe sex since HAART availability was significantly associated with an increased likelihood of HIV seroconversion.

CONCLUSIONS

The results support the assumption that there is an association between the incidence of STDs and a decreased perception of HIV/AIDS threat resulting from HAART availability. Less perceived need for safe sex since HAART availability was associated with HIV seroconversion.

Sexual tourism: implications for travelers and the destination culture

Health care providers in a variety of settings need to improve their ability--along with the capabilities of supporting laboratories, surveillance systems, and services for sex partner management--to diagnose and treat STI. Whether the travel health care sector, as such, is willing to take on the additional burden of STI-related screening and risk reduction counseling has been raised by some authors. Currently, the burden of providing formalized STI care falls on the public sector; however, in the United States, most STI are actually diagnosed in the offices of private physicians. Given that the United States has the highest STI rates of any industrialized country, the undeniable synergy between STI and HIV acquisition, the failure of many American providers to screen for C trachomatis despite clear guidelines, the global resurgence of syphilis and extension of resistant N gonorrhoeae and of HIV, and the risk behaviors consistently reported by travelers, it is hard to argue against travel specialists' joining the daunting battle against these recalcitrant infections and their often devastating consequences. Most of the relevant diagnostic tests are relatively affordable, and patient-centered risk-reduction counseling, once mastered, can be brief and easily integrated into the overall conversation about protecting oneself during travel.

Management of occupational and nonoccupational postexposure HIV prophylaxis

The principles of managing patients with recent HIV exposures are similar whether the exposure occurs in an occupational or nonoccupational setting. For both settings, clinicians should 1) assess the likelihood that HIV and other bloodborne viruses will be transmitted as a consequence of the exposure; 2) advise the patient about the risks and benefits of treatment; 3) choose an appropriate antiretroviral treatment regimen (if the decision is made to treat); 4) screen for other illnesses that may complicate treatment or follow-up; 5) counsel patients about the importance of adhering to treatment; 6) promote safe-sex practices and methods to avoid future exposures; 7) follow the patient for potential side effects of treatment; 8) provide follow-up care including repeat HIV testing for seroconversion, surveillance for primary HIV infection, and reinforcement of counseling messages.

Chronic HIV-2 infection protects against total CD4+ cell depletion and rapid disease progression induced by SHIV89.6p challenge

OBJECTIVE

To better understand HIV-1 sexual transmission risk, we have studied the susceptibility of HIV-2-exposed, uninfected (EU) female pig-tailed macaques to intravaginal (IVAG) re-challenge with the homologous HIV-2 strain, followed by heterologous SHIV89.6p.

METHODS

Nine female macaques, previously protected by a post-exposure prophylaxis (PEP) regimen, along with one mock-treated EU animal, were re-exposed to HIV-2 by the IVAG route approximately 1.5 years later. A single follow-up challenge was performed approximately 1 year later with SHIV89.6p to assess susceptibility of chronic HIV-2-infected animals to further re-infection and pathogenic effects with a heterologous virus, somewhat mimicking HIV-1.

RESULTS

Eight of ten macaques (80%) became infected systemically with HIV-2, and plasma or cervicovaginal vRNA levels did not appreciably differ from prior historic non-PEP control macaques. Interestingly, all eight HIV-2-infected females were susceptible to SHIV89.6p infection by either intravenous (n = 4) or IVAG exposure (n = 4) after one inoculation. Plasma vRNA levels in these groups were controlled by week 8 and there were no decrease in CD4+ T cells > 50%. The remaining two HIV-2 EU macaques, inoculated intrarectally with SHIV89.6p, were unable to control virus replication and succumbed to disease by week 25 or week 61.

CONCLUSIONS

Our findings demonstrate that successful PEP regimens to prevent an initial infection do not have any lasting protective effects. The observed lack of cross-protection against SHIV89.6p transmission among chronic HIV-2-infected macaques provides modeling support for limited epidemiologic data indicating that human HIV-2 infection does not protect against HIV-1 infection, but may serve to alter overt clinical outcome.

Primary HIV type 1 infection

Emerging evidence suggests that early events in human immunodeficiency virus type 1 (HIV-1) infection may play a critical role in determining disease progression. Although there is limited evidence on which to base medical decisions, the diagnosis and treatment of acute HIV-1 infection may have virologic, immunologic, and clinical benefits. In addition, rapid diagnosis of infection may prevent unknowing transmission of HIV-1 during a period of high-level viremia. We review the basic principles of primary HIV-1 infection, clinical and diagnostic markers of acute seroconversion, approaches to management, and new therapeutic strategies.

Knowledge of HIV Postexposure Prophylaxis in a Population of HIV-Positive Outpatients: Results of a French National Survey

Since 1998, French HIV guidelines have recommended use of HIV prophylaxis after unprotected sex (postexposure prophylaxis, or PEP) with an HIV-positive partner. To characterize factors associated with lack of PEP knowledge in an HIV-positive population, a cross-sectional survey was conducted of 737 French HIV-positive outpatients followed in AIDS care units of 2 regions accounting for 60% of French AIDS cases. Information was collected through face-to-face interviews. The sample was weighted to improve national validity. Median age was 41 years, 73.2% of patients were male, and 8.5% reported HIV-related risk behaviors. Those who knew about PEP and those who did not were compared with chi2 tests and logistic regression. One third of the sample had never heard of PEP. In multivariate analysis, lack of PEP knowledge was associated with older age, low educational level, unstable housing, unawareness of current HIV laboratory data, and lack of ability to confide in nurse and to seek out information from various sources. The increased number of people living with HIV infection as a chronic disease raises new challenges for its secondary prevention. Preventive programs aimed at HIV-positive individuals and their sexual partners are strongly needed.

Rape and HIV post-exposure prophylaxis: addressing the dual epidemics in South Africa

In South Africa, a country notable for both a rapidly escalating AIDS epidemic and high levels of sexual violence, the issue of HIV post-exposure prophylaxis (PEP) following rape has recently come to the fore, and a policy supporting provision of PEP has been approved by the national government. This paper compares the conditions for providing PEP in Europe and North America with the conditions faced by two initiatives in South Africa, one serving a primarily rural base, and one urban. It is based on a review of the literature on sexual violence in South Africa and use of PEP following occupational and non-occupational exposure. It incorporates perspectives from in-depth interviews in 2000 with 18 key informants, including survivors of sexual violence, gender and HIV activists, domestic violence NGOs, rape crisis centres, physicians, lawyers, researchers and HIV/AIDS advisors in the Department of Health. The paper argues that given the scientific evidence for PEP, and the nature of the dual epidemics of HIV and sexual violence in South Africa, the public health and social justice rationale for implementing PEP equals and indeed exceeds that put forward in industrialised countries. However, delays in accessing PEP caused by the public justice system and lack of training for service providers constitute significant obstacles to effective implementation. In this respect, provision of PEP presents an opportunity to reform and strengthen existing services for post-rape care and to link attention to the epidemic of sexual violence to HIV/AIDS prevention.

Recommendations for incorporating human immunodeficiency virus (HIV) prevention into the medical care of persons living with HIV

The estimated number of annual new human immunodeficiency virus (HIV) infections in the United States has remained at 40,000 for >10 years. Reducing the rate of transmission will require new strategies, including emphasis on prevention of transmission by HIV-infected persons. Medical care providers can affect HIV transmission by screening HIV-infected patients for risk behaviors, communicating prevention messages, discussing sexual and drug-use behaviors, reinforcing changes to safer behavior, referring patients for services such as substance abuse treatment, facilitating partner counseling and referral, and identifying and treating other sexually transmitted diseases. The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the National Institutes of Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) have recently collaborated to develop evidence-based recommendations for incorporating HIV prevention into the medical care of persons living with HIV. This article summarizes key aspects of the recommendations.

Evaluation and management of the sexually assaulted woman

The evaluation and management of the sexually assaulted woman is a challenging task that emergency physicians frequently face. The physician must assume dual roles as advocate for the patient and as an agent of the government. While caring for the immediate physical and emotional well being of the victim, the physician also must be diligent in the forensic evaluation and evidence collection. To receive quality care, the victim should receive a thorough history and physical examination with appropriate diagnosis and treatment of injuries, a thorough evidentiary examination, counseling and treatment for prevention of pregnancy and STDs, provisions for initial and ongoing mental health evaluation, and appropriate follow-up. To provide this high quality care, the physician must be familiar with the process of the evidentiary examination, have knowledge of the current recommendations for pregnancy and STD prophylaxis. and have thorough knowledge of the community resources that are available.

Postexposure prophylaxis: an intervention to prevent human immunodeficiency virus infection in adolescents

Postexposure prophylaxis is an effective intervention to prevent transmission of the human immunodeficiency virus (HIV). Administration of antiretroviral medications within 72 hours of a percutaneous or mucous membrane exposure to HIV can prevent infection. The use of postexposure prophylaxis for occupational and perinatal HIV exposures is well established. Its efficacy for nonoccupational exposures has only recently been studied. To date in the United States, there are no national guidelines regarding postexposure prophylaxis for nonoccupational exposures. Decisions regarding its use should be made after weighing the risks of seroconversion for a given exposure, the risks of HIV in the source, and the potential toxicities of the antiretroviral medications. Several state guidelines may also serve as important resources. Clinicians should consider initiating postexposure prophylaxis in adolescents for any oral, anal, or vaginal exposure to definitely or possibly HIV-infected blood or body fluids. Adolescents treated should be followed closely for medication toxicity, acute seroconversion, and risk-reduction counseling. Further studies are needed to characterize the use and efficacy of postexposure prophylaxis in an adolescent population.

Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus

Exposure to human immunodeficiency virus (HIV) can occur in a number of situations unique to, or more common among, children and adolescents. Guidelines for postexposure prophylaxis (PEP) for occupational and nonoccupational (eg, sexual, needle-sharing) exposures to HIV have been published by the US Public Health Service, but they do not directly address nonoccupational HIV exposures unique to children (such as accidental exposure to human milk from a woman infected with HIV or a puncture wound from a discarded needle on a playground), and they do not provide antiretroviral drug information relevant to PEP in children. This clinical report reviews issues of potential exposure of children and adolescents to HIV and gives recommendations for PEP in those situations. The risk of HIV transmission from nonoccupational, nonperinatal exposure is generally low. Transmission risk is modified by factors related to the source and extent of exposure. Determination of the HIV infection status of the exposure source may not be possible, and data on transmission risk by exposure type may not exist. Except in the setting of perinatal transmission, no studies have demonstrated the safety and efficacy of postexposure use of antiretroviral drugs for the prevention of HIV transmission in nonoccupational settings. Antiretroviral therapy used for PEP is associated with significant toxicity. The decision to initiate prophylaxis needs to be made in consultation with the patient, the family, and a clinician with experience in treatment of persons with HIV infection. If instituted, therapy should be started as soon as possible after an exposure-no later than 72 hours-and continued for 28 days. Many clinicians would use 3 drugs for PEP regimens, although 2 drugs may be considered in certain circumstances. Instruction for avoiding secondary transmission should be given. Careful follow-up is needed for psychologic support, encouragement of medication adherence, toxicity monitoring, and serial HIV antibody testing.

Human immunodeficiency virus in the parturient

Over the last 20 years, the acquired immune deficiency syndrome (AIDS) has grown from a small case series of Pneumocystis carinii infection in four homosexual men to one of the major health problems facing the world today. In the next 5 years, human immunodeficiency virus (HIV) infection is expected to kill more than 2.2 million people. In the United States, women of childbearing age constitute a large percentage of new cases of AIDS. Because of the increased prevalence of HIV in pregnant women, many anesthesiologists encounter these patients in their practice. The safety of regional neuraxial spread has been a concern in the past, nevertheless, recent analysis of the problem has shown that HIV infection in pregnancy does not contraindicate administration of regional anesthesia.

Occupationally acquired human immunodeficiency virus (HIV) infection: national case surveillance data during 20 years of the HIV epidemic in the United States

OBJECTIVE

To characterize occupationally acquired human immunodeficiency virus (HIV) infection detected through case surveillance efforts in the United States.

DESIGN

National surveillance systems, based on voluntary case reporting.

SETTING

Healthcare or laboratory (clinical or research) settings.

PATIENTS

Healthcare workers, defined as individuals employed in healthcare or laboratory settings (including students and trainees), who are infected with HIV.

METHODS

Review of data reported through December 2001 in the HIV/AIDS Reporting System and the National Surveillance for Occupationally Acquired HIV Infection.

RESULTS

Of 57 healthcare workers with documented occupationally acquired HIV infection, most (86%) were exposed to blood, and most (88%) had percutaneous injuries. The circumstances varied among 51 percutaneous injuries, with the largest proportion (41%) occurring after a procedure, 35% occurring during a procedure, and 20% occurring during disposal of sharp objects. Unexpected circumstances difficult to anticipate during or after procedures accounted for 20% of all injuries. Of 55 known source patients, most (69%) had acquired immunodeficiency syndrome (AIDS) at the time of occupational exposure, but some (11%) had asymptomatic HIV infection. Eight (14%) of the healthcare workers were infected despite receiving postexposure prophylaxis (PEP).

CONCLUSIONS

Prevention strategies for occupationally acquired HIV infection should continue to emphasize avoiding blood exposures. Healthcare workers should be educated about both the benefits and the limitations of PEP, which does not always prevent HIV infection following an exposure. Technologic advances (eg, safety-engineered devices) may further enhance safety in the healthcare workplace.

Post-exposure prophylaxis

The mean risk of acquiring HIV after an occupational exposure, injecting drug use or sexual exposure varies from < 0.1 to 3%. A high plasma HIV-RNA of the source increases the risk of each of the exposures. Other factors, such as the volume of the inoculum involved to which the individual was exposed, other sexually transmitted diseases and ruptures of mucous membranes are associated with a higher risk of HIV transmission. Based on the calculated risk, post-exposure prophylaxis (PEP) should be recommended. In the Netherlands, prescription of PEP in the occupational setting is a standard procedure and has proved to be feasible. This was associated with a high percentage (62%) of mild and reversible toxicity and a small percentage (2%) of serious adverse events related to antiretroviral drugs, i.e. nephrolithiasis (due to indinavir) and toxic hepatitis (due to nevirapine). In The Netherlands so far no HIV-seroconversions have been recorded after an occupational accident.

Management of Occupational and Nonoccupational Postexposure HIV Prophylaxis

The principles of managing patients with recent HIV exposure are similar whether the exposure occurs in an occupational or nonoccupational setting. For both settings, clinicians should assess the likelihood that HIV and other bloodborne viruses will be transmitted as a consequence of the exposure; advise the patient about the risks and benefits of treatment; choose an appropriate antiretroviral treatment regimen (if the decision is made to treat); screen for other illnesses that may complicate treatment or follow-up; counsel patients about the importance of adhering to treatment; promote safe-sex practices and methods to avoid future exposures; follow the patient for potential side effects of treatment; and provide follow-up care including repeat HIV testing for seroconversion, surveillance for primary HIV infection, and reinforcement of counseling messages.

[Recommendations for non-occupational postexposure HIV prophylaxis. Spanish Working Group on Non-Occupational Postexposure HIV Prophylaxis of the Catalonian Center for Epidemiological Studies on AIDS and the AIDS Study Group]

Evidence is lacking on the possible efficacy and effectiveness of non-occupational postexposure prophylaxis (PEP). However, because of its biological plausibility, the use of antiretroviral (ARV) drugs to prevent the development of infection in certain cases of accidental or sporadic exposure has begun to be considered as common clinical practice. Previous studies performed in Spain have demonstrated both the demand and the prescription of ARV as PEP and especially the diversity and inconsistency in the criteria used. In this context, in April of 2000 the Centre for Epidemiological Studies on AIDS of Catalonia (CEESCAT) (Department of Health and Social Security of the Autonomous Government of Catalonia), in collaboration with the National AIDS Plan and the AIDS Study Group (GESIDA), promoted the creation of a working group for the drafting of recommendations for PEP against HIV outside the occupational health context. The recommendations have been made bearing in mind the exceptional character of the exposure, the time elapsed since exposure, as well as evaluation of the risk of infection according to the type of exposure and the information available on the source of infection. In addition, the recommendations include the immediate measures necessary, as well as the preventive measures and clinical follow-up required both for HIV and for other infectious agents. All PEP regimens should be started within 72 hours of exposure and appropriate daily doses of two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI), or two NRTIs and a non-nucleoside reverse transcriptase inhibitor (NNRTIs), should be administered for four weeks, bearing in mind the pharmacological and clinical situation of the source person. These recommendations should be updated periodically.

[Recommendations of the Spanish AIDS Study Group (GESIDA) and the National Aids Plan (PNS) for antiretroviral treatment in adult patients with human immunodeficiency virus infection in 2002]

OBJECTIVE

To provide an update of recommendation on antiretroviral treatment (ART) in HIV-infected adults.Methods. These recommendations have been agreed by consensus by a committee of the spanish AIDS Study Group (GESIDA) and the National AIDS Plan. To do so, advances in the physiopathology of AIDS and the results on efficacy and safety in clinical trials, cohort and pharmacokinetics studies published in biomedical journals or presented at congresses in the last few years have been reviewed. Three levels of evidence have been defined according to the data source: randomized studies (level A), case-control or cohort studies (level B) and expert opinion (level C). Whether to recommend, consider, or not to recommend ART has been established for each situation.

RESULTS

Currently, ART with combinations of at least three drugs constitutes the treatment of choice in chronic HIV infection. In patients with symptomatic HIV infection, initiation of ART is recommended. In asymptomatic patients initiation of ART should be based on the CD41/mL lymphocyte count and on the plasma viral load (PVL): a) in patients with CD41 lymphocytes < 200 cells/mL, initiation of ART is recommended; b) in patients with CD41 lymphocytes between 200 and 300 cells/mL, initiation of ART should, in most cases, be recommended; however, it could be delayed when the CD41 lymphocyte count remains close to 350 cells/mL and the PVL is low, and c) in patients with CD41 lymphocytes > 350 cells/mL, initiation of ART can be delayed. The aim of ART is to achieve an undetectable PVL. Adherence to ART plays a role in the durability of the antiviral response. Because of the development of cross-resistance, the therapeutic options in treatment failure are limited. In these cases, genotypic analysis is useful. Toxicity limits ART. The criteria for ART in acute infection, pregnancy and postexposure prophylaxis and in the management of coinfection with HIV and hepatitis C and B virus are controversial.

CONCLUSIONS

The current approach to initiating ART is more conservative than in previous recommendations. In asymptomatic patients, the CD41 lymphocyte count is the most important reference factor for initiating ART. Because of the considerable number of drugs available, more sensitive monitoring methods (PVL) and the possibility of determining resistance, therapeutic strategies have become much more individualized.

Spare non-occupational HIV post-exposure prophylaxis by active contacting and testing of the source person

OBJECTIVE

HIV-1 post-exposure prophylaxis (PEP) is frequently prescribed after exposure to source persons with an undetermined HIV serostatus. To reduce unnecessary use of PEP, we implemented a policy including active contacting of source persons and the availability of free, anonymous HIV testing ('PEP policy').

METHODS

All consultations for potential non-occupational HIV exposures i.e. outside the medical environment) were prospectively recorded. The impact of the PEP policy on PEP prescription and costs was analysed and modelled.

RESULTS

Among 146 putative exposures, 47 involved a source person already known to be HIV positive and 23 had no indication for PEP. The remaining 76 exposures involved a source person of unknown HIV serostatus. Of 33 (43.4%) exposures for which the source person could be contacted and tested, PEP was avoided in 24 (72.7%), initiated and discontinued in seven (21.2%), and prescribed and completed in two (6.1%). In contrast, of 43 (56.6%) exposures for which the source person could not be tested, PEP was prescribed in 35 (81.4%), P < 0.001. Upon modelling, the PEP policy allowed a 31% reduction of cost for management of exposures to source persons of unknown HIV serostatus. The policy was cost-saving for HIV prevalence of up to 70% in the source population. The availability of all the source persons for testing would have reduced cost by 64%.

CONCLUSION

In the management of non-occupational HIV exposures, active contacting and free, anonymous testing of source persons proved feasible. This policy resulted in a decrease in prescription of PEP, proved to be cost-saving, and presumably helped to avoid unnecessary toxicity and psychological stress.

The relation between beliefs about drug treatments for HIV and sexual risk behavior in gay and bisexual men

This study examined the relation between gay and bisexual men's (N = 575) beliefs about highly active antiretroviral therapy (HAART) and other HIV-related beliefs, intentions, and risk behaviors. Confirmatory factor analysis verified three belief factors: the extent to which HAART improves health among HIV-infected individuals, decreases the risk of HIV transmission, and is complicated and of limited efficacy. Men who endorsed the belief that HAART decreases HIV transmission risk expressed lower intentions to use condoms for anal sex and were more likely to have engaged in unprotected anal intercourse with a casual partner HIV-negative men who believed that HAART decreases transmission risk also perceived themselves to be more susceptible to HIV infection. Statistical evidence indicated that perceptions of susceptibility partially mediate the relation between sexual risk behavior and beliefs about HAART suggesting that beliefs may result from, rather than cause, increased risk behavior.