Adherence, adverse drug reactions, and discontinuation associated with adverse drug reactions of HIV post-exposure prophylaxis: a meta-analysis based on cohort studies

Objective: Evaluate the profiles of post-exposure prophylaxis (PEP) adherence, adverse drug reactions (ADRs), and discontinuation associated with ADRs to provide information for further PEP program improvement and increase adherence to PEP.Methods: The Web of Science, PubMed, Embase, and the Cochrane Library were searched for cohort studies reporting data related to PEP adherence or ADRs (PROSPERO, CRD42022385073). Pooled estimates of adherence, the incidence of ADRs and discontinuation associated with ADRs, and their 95% confidence intervals (CI) were calculated separately for the included literature using random effects models. For substantial heterogeneity, meta-regression and subgroup analyses were conducted to explore sources of heterogeneity.Results: Overall adherence was 58.4% (95% CI: 50.9%-65.8%), with subgroup analysis showing differences in adherence across samples, with the highest adherence among men who had sex with men (MSM) (72.4%, 95% CI: 63.4%-81.3%) and the lowest adherence among survivors of sexual assault (SAs) (41.7%, 95% CI: 28.0%-55.3%). The incidence of ADRs was 60.3% (95% CI: 50.3%-70.3%), and the prevalence of PEP discontinuation associated with ADRs was 32.7% (95% CI: 23.7%-41.7%), with subgroup analyses revealing disparities in the prevalence of discontinuation associated with ADRs among samples with different drug regimens. Time trend analysis showed a slight downward trend in the incidence of ADRs and PEP discontinuation associated with ADRs.Conclusion: Adherence to PEP was less than 60% across samples, however, there was significant heterogeneity depending on the samples. SAs had the lowest adherence and the highest incidence of PEP discontinuation. Ongoing adherence education for participants, timely monitoring, and management of ADRs may improve adherence.

Is non-occupational HIV Post Exposure Prophylaxis (nPEP) still used? An exploration of nPEP use since widespread availability of HIV PrEP

BACKGROUND

Non-occupational Post-Exposure Prophylaxis (nPEP) is an effective HIV prevention strategy in gay and bisexual men (GBM) taken after possible exposure. HIV Pre-Exposure Prophylaxis (PrEP) is also a highly effective HIV prevention strategy.

METHODS

A retrospective audit of medical records of GBM presenting to a sexual health centre and provided with nPEP compared two periods to determine if nPEP usage changed following availability of PrEP. In the first period (P1) PrEP was available through extended trials. In the second period (P2) PrEP became more accessible through the Australian Pharmaceutical Benefits Scheme (PBS). Period comparisons were performed using a two-population test of proportions with one-tailed testing and significance set at P < .05 using SPSS Statistics Version 25.

RESULTS

There were 232 GBM provided with nPEP in P1, and 202 in P2. A two-population test of proportions demonstrated that GBM presentations for nPEP decreased significantly from 302/4779 (6.3%) of GBM visits in P1 to 221/7205 (3.1%) in P2 when PrEP was more accessible (Z=8.53, P < .001). PrEP uptake after presenting for nPEP increased from 30 (12.9%) of total GBM visits in P1 to 69 (34.2%) in P2 (Z=5.26, p < .001).

CONCLUSIONS

GBM accessing nPEP decreased with statistical significance post introduction of PBS PrEP.

Implementation of HIV non-occupational post-exposure prophylaxis for men who have sex with men in 2 cities of Southwestern China

ABSTRACT

Non-occupational post-exposure prophylaxis (nPEP) has often relied on the joint work of emergency physicians and infectious disease specialists in busy emergency departments and human immunodeficiency virus (HIV)/sexually transmitted infections clinics abroad, where adherence education and follow-up are invariably reactive. In our pilot study, community-based organizations (CBOs) were invited to together implement the nPEP tailored to men who have sex with men (MSM) in 2 cities of Guangxi in Southwestern China, of which experiences and lessons drawn from would be provided to the promotion of nPEP in China.The study population enrolled MSM individuals prescribed nPEP from September 2017 to December 2019. One-to-one follow-ups by CBOs were applied through the treatment. Predictors of treatment completion were assessed by logistic regression.Of 271 individuals presented for nPEP, 266 MSM with documented treatment completion or non-completion, 93.6% completed the 28-day course of medication. Completion was associated with reporting side effects (aOR = .10; 95% CI: 0.02-0.38; P = .001). The follow-up rate of 91.9% was achieved based on the definition of loss to follow-up. No documented nPEP failures were found, although 1 MSM subsequently seroconverted to HIV due to ongoing high-risk behavior.CBOs' engagement in HIV nPEP, especially the "one-to-one" follow-up supports by peer educators partly ensure adherence and retention to nPEP. Tailored interventions are needed to address the subsequent high-risk behaviors among the MSM population.

HIV Nonoccupational Postexposure Prophylaxis Among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis of Global Data

HIV nonoccupational postexposure prophylaxis (nPEP) has been prescribed to men who have sex with men (MSM) for decades, but the global situation of nPEP implementation among this population remains unclear. To understand nPEP awareness, uptake, and factors associated with uptake among MSM, we searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science for studies reporting nPEP implementation among MSM published before May 19, 2019. We estimated pooled rates and their 95% confidence intervals (CIs) of awareness, uptake using a random-effects model. We identified 74 studies: 3 studies (4.1%) from upper-middle-income regions and 71 (95.9%) from high-income regions. The pooled rate of nPEP awareness and uptake was 51.6% (95% CI 40.6-62.5%) and 6.0% (5.0-7.1%), respectively. Pooled uptake rate was higher in upper-middle-income regions [8.9% (7.8-10.0%)] than in high-income regions [5.8% (4.8-6.9%)]. Unprotected anal sex was the most common exposure (range: 55.0-98.6%, median: 62.9%). Pooled completion of nPEP was 86.9% (79.5-92.8%). Of 19,546 MSM prescribed nPEP, 500 HIV seroconversions (2.6%) were observed. Having risky sexual behaviors and history of sexually transmitted infections were associated with higher nPEP uptake, whereas insufficient knowledge, underestimated risk of exposure to HIV, lack of accessibility, and social stigma might hinder nPEP uptake. Awareness and uptake of nPEP among MSM worldwide are low. Further efforts are needed to combat barriers to access nPEP, including improving accessibility and reducing stigma. Seroconversions post-nPEP uptake suggest that joint prevention precautions aside from nPEP are needed for high-risk MSM. More evidence from low-income and middle-income regions is needed.

A mixed methods study of non-occupational post-exposure prophylaxis at an STI clinic in Singapore: Five-year retrospective analysis and providers' perspectives

BACKGROUND

This mixed methods study aims to describe 1) characteristics of the population treated with non-occupational post-exposure prophylaxis (nPEP), 2) predictors of loss to follow-up (LTFU) and nPEP adherence, and 3) to evaluate the nPEP prescribing practices against current management guideline.

METHODS

This study was conducted at the Department of Sexually Transmitted Infections Control Clinic in Singapore using clinical data from 2010 to 2016. Explanatory sequential mixed method design was adopted. Predictors of LTFU and nPEP adherence were assessed using modified Poisson regression with robust sandwich variance. Subsequently, nine in-depth interviews with healthcare providers were conducted to gain their insights into barriers and facilitators to nPEP implementation. Transcripts were coded and themes were explored using applied thematic analysis.

RESULTS

Of 502 nPEP cases reviewed, 46% were LTFU, 42% were adherent to nPEP and 431 prescription decisions were made in accordance with the guideline. Tourists (aRR, 2.29 [1.90-2.74]; p<0.001) and men who have sex with men/bisexual men (aRR, 1.32 [1.09-1.59]; p = 0.004) were significant predictors of LTFU. Absence of side effects (aRR, 1.14 [1.02-1.27]; p = 0.024) and nPEP treatment with TDF/FTC/ATV/r (aRR, 1.15 [1.03-1.29]; p = 0.017) were positively associated with nPEP adherence. Stigma, types of antiretroviral regimen, side effects, and patients' perception of risk and treatment benefits derived qualitatively further reinforced corresponding quantitative findings.

CONCLUSION

Tailored socio-behavioral interventions are needed to address inherent differences within heterogeneous populations requesting nPEP, stigma, and patients' perceptions of nPEP in order to improve follow-up and its adherence.

Evaluation of tolerability with the co-formulation elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate for post-HIV exposure prophylaxis

Background

The preferred regimen for HIV post-exposure prophylaxis (PEP) is based mainly on safety and tolerability because it is given to immunocompetent people without HIV infection for a limited time (28 days). The frequency of adverse events (AEs) may be > 60%. Although AEs are generally not severe, they can lead to lack of adherence and failure to complete the regimen. We evaluated the co-formulation elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate (Stribild^®) prescribed as one pill taken once daily for HIV PEP in terms of tolerability and adherence.

Methods

This was a prospective cohort study conducted in one hospital in Paris (April to December 2015. Each participant receiving the PEP treatment (FTC-150 mg/TDF-245 mg/elvitegravir-200 mg/cobicistat 150 mg once daily) at the pharmacy of the hospital were recruited consecutively. A clinical visit was planned at 8 weeks after sexual exposure. Reminders were sent to participants who missed the appointment. A standardized questionnaire was administered to evaluate completeness and tolerability at week 8.

Results

Overall, 284 participants (86% men; 80% MSM; median age 30 years) were prescribed Stribild^®; 50 stopped after reassessment of risk. Among 234 participants who effectively received PEP, 215 (92%) completed 28 days of PEP with only three who switched from Stribild^® to another PEP because of side effects. More than 60% of participants reported at least one AE, which were mild to moderate. Fatigue, central neurological and abdominal side effects were the most frequently reported.

Conclusions

Stribild^® seems to be a good option for HIV PEP due to the easiness of use, the side effects profile and the high completion rate.

Choice of antiretroviral drugs for postexposure prophylaxis for adults and adolescents: a systematic review

BACKGROUND

The choice of preferred regimens for human immunodeficiency virus postexposure prophylaxis (PEP) has evolved over the last 2 decades as more data have become available regarding the safety and tolerability of newer antiretroviral drugs. We undertook a systematic review to assess the safety and efficacy of antiretroviral options for PEP to inform the World Health Organization guideline revision process.

METHODS

Four databases were searched up to 1 June 2014 for studies reporting outcomes associated with specific PEP regimens. Data on PEP completion and discontinuation due to adverse events was extracted and pooled estimates were obtained using random-effects meta-analyses.

RESULTS

Fifteen studies (1830 PEP initiations) provided evaluable information on 2-drug regimens (zidovudine [ZDV]- or tenofovir [TDF]-based regimens), and 10 studies (1755 initiations) provided evaluable information on the third drug, which was usually a protease inhibitor. The overall quality of the evidence was rated as very low. For the 2-drug regimen, PEP completion rates were 78.4% (95% confidence interval [CI], 66.1%-90.7%) for people receiving a TDF-based regimen and 58.8% (95% CI, 47.2%-70.4%) for a ZDV-based regimen; the rate of PEP discontinuation due to an adverse event was lower among people taking TDF-based PEP (0.3%; 95% CI, 0%-1.1%) vs a ZDV-based regimen (3.2%; 95% CI, 1.5%-4.9%). For the 3-drug comparison, PEP completion rates were highest for the TDF-based regimens (TDF+emtricitabine [FTC]+lopinavir/ritonavir [LPV/r], 71.1%; 95% CI, 43.6%-98.6%; TDF+FTC+raltegravir [RAL], 74.7%; 95% CI, 41.4%-100%; TDF+FTC+ boosted darunavir [DRV/r], 93.9%; 95% CI, 90.2%-97.7%) and lowest for ZDV+ lamivudine [3TC]+LPV/r (59.1%; 95% CI, 36.2%-82.0%). Discontinuations due to adverse drug reactions were lowest for TDF+FTC+RAL (1.9%; 95% CI, 0%-3.8%) and highest for ZDV+3TC+boosted atazanavir (21.2%; 95% CI, 13.5%-30.0%).

CONCLUSIONS

The findings of this review provide evidence supporting the use of coformulated TDF and 3TC/FTC as preferred backbone drugs for PEP. Choice of third drug will depend on setting; for resource-limited settings, LPV/r is a reasonable choice, pending the improved availability of better-tolerated drugs with less potential for drug-drug interactions.

Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review

BACKGROUND

The provision of starter packs for human immunodeficiency virus postexposure prophylaxis (PEP) is practiced in many settings to facilitate rapid initiation by nonexperts and encourage adherence. However, the impact of starter packs on PEP completion rates has not been systematically assessed. We systematically reviewed the evidence on outcomes associated with starter packs for PEP compared to full prescriptions.

METHODS

Four databases and 2 conference abstract sites were searched up to December 2013; this search was updated in 1 database in June 2014. PEP completion rates, stratified by prescribing practice, were pooled using random-effects meta-analysis.

RESULTS

Fifty-four studies provided data on 11 714 PEP initiations. Thirty-seven studies, including 3 randomized controlled trials (RCTs) and 34 observational cohorts, provided information on starter packs (although none of the RCTs specifically assessed starter packs), and 17 studies, including 2 RCTs and 15 observational cohorts, provided information on full prescriptions. Overall, outcomes were better when participants were offered a full 28-day course of PEP at initial presentation to healthcare, with fewer refusals (11.4% [95% confidence interval {CI}, 5.3%-17.5%] vs 22% [95% CI, 16.7%-28.1%]) and higher completion rates (70% [95% CI, 56.7%-77.3%] vs 53.2% [95% CI, 44.4%-62.2%]). More than a quarter (28% [95% CI, 21.4%-34.5%]) of individuals provided with a PEP starter pack failed to return for their subsequent appointment and therefore defaulted prior to receiving a full course of PEP. The quality of the evidence overall was rated as very low.

CONCLUSIONS

The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates.

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.

Adherence to Post-Exposure Prophylaxis (PEP) and Incidence of HIV Seroconversion in a Major North American Cohort

Background

There is limited evidence on the efficacy of post-exposure prophylaxis (PEP) for sexual exposures. We sought to determine the factors associated with adherence to treatment and describe the incidence of PEP failures in a Montreal clinic.

Methods

We prospectively assessed all patients consulting for PEP following sexual exposures from October 2000 to July 2014. Patients were followed at 4 and 16 weeks after starting PEP. Treatment adherence was determined by self-report at week 4. Multivariable logistic regression was used to estimate the factors predicting adherence to treatment.

Results

3547 PEP consults were included. Patients were mainly male (92%), MSM (83%) and sought PEP for anal intercourse (72%). Seventy-eight percent (n = 2772) of patients received a prescription for PEP, consisting of Tenofovir/Emtracitabine (TVD) + Lopinavir/Ritonavir (LPV) in 74% of cases, followed by Zidovudine/Lamivudine (CBV) + LPV (10%) and TVD + Raltegravir (RAL) (8%). Seventy percent of patients were adherent to treatment. Compared to TVD+LPV, patients taking CBV+LPV were less likely to adhere to treatment (OR 0.58, 95% CI 0.44–0.75), while no difference was observed for patients taking TVD+RAL (OR 1.15, 95% CI 0.83–1.59). First-time PEP consults, older and male patients were also more adherent to treatment. Ten treated patients seroconverted (0.37%) during the study period, yet only 1 case can be attributed to PEP failure (failure rate = 0.04%).

Conclusion

PEP regimen was associated with treatment adherence. Patients were more likely to be adherent to TVD-based regimens. Ten patients seroconverted after taking PEP; however, only 1 case was a PEP failure as the remaining patients continued to engage in high-risk behavior during follow-up. One month PEP is an effective preventive measure to avoid HIV infection.