Assessment of adverse events associated with antiretroviral regimens for postexposure prophylaxis for occupational and nonoccupational exposures to prevent transmission of human immunodeficiency virus

Health care services for survivors of gender-based violence: a community and clinic-based intervention in Zambézia province, Mozambique

Mozambique introduced guidelines for integrated gender-based violence (GBV) services in 2012. In 2017, we trained providers on empathetic and supportive services to GBV survivors and introduced home-based services for survivors who are loss-to-follow up. Rate ratios of clinic visits were compared before and after intervention initiation, using exact significance tests. Data of 1,806 GBV survivors were reviewed, with a total of 2005 events. The median age was 23 years (IQR 17-30) and 89% were women. Among those reporting violence, 69% reported physical violence, 18% reported sexual violence (SV), and 12% reported psychological violence. Rates of care-seeking behavior were higher in the intervention period (rate ratio 1.31 [95%CI: 1.18-1.46]); p < 0.01. Among those eligible for post-exposure prophylaxis (PEP), 94% initiated PEP. Uptake of HIV retesting improved in percentage points by 34% (14% to 48%), 34% (8% to 42%) and 26% (5% to 31%) at 1-, 3- and 6-months, respectively. The intervention led to an increase in the rate of GBV survivors seeking health care services, and improved rates of follow-up care among SV survivors initiating PEP. Strengthening of PEP adherence counseling remains crucial for improving GBV services.

A Qualitative Study of Perceived Risk of Occupational Exposure to HIV and Use of Post Exposure Prophylaxis Services Among Health-Care Workers in Tanzania

Background:

Occupational exposure to HIV continues to present a risk of HIV infections to health-care workers (HCWs) in low-income countries. Since 2005, policies in Tanzania have been in place to guide the implementation of HIV/AIDS post-exposure prophylaxis (PEP) interventions in the workplace. However, little is known about how frontline HCWs experience and view these interventions. This study aimed to explore how HCWs perceive their HIV infection risk and capture their experiences of workplace HIV/AIDS interventions.

Methods:

A descriptive qualitative design was used. Medical and nonmedical personnel from 2 hospitals in the Pwani and Dodoma regions of Tanzania participated in the study. We conducted 22 In-depth interviews (IDIs) with HCWs (heads of departments, hospital units, or sections). A content analysis approach was used.

Results:

The HCWs perceived and reasoned that working in medical wards, incinerator units, dental units, obstetric wards, laundries, laboratories, and mortuaries exposed them to HIV acquisition risk. Many of the medically trained personnel reported that invasive procedures exposed them to some risk of HIV infection. Nonmedical personnel reported to be potentially exposed to HIV infection while incorrectly handling discarded needles and blades (sharps). Although most HCWs expressed awareness about the availability of postexposure prophylaxis (PEP), not all HCWs knew where to report and whom to contact in case of accidents. Ignorance about the implications of exposure to contaminated sharps hindered PEP use among certain cadres. Also, some PEP users were reported to experience side effects, but they were motivated to complete the doses to remain healthy.

Conclusion:

Occupational exposure to HIV infection remains a significant concern to HCWs, particularly among nonmedical cadres. Despite expressed awareness about infection prevention and control, the reporting channels and the strategies to promote recognition of the importance of using PEP services after exposure need to be strengthened.

Suspected unexpected and other adverse reactions to antiretroviral drugs used as post-exposure prophylaxis of HIV infection - five-year experience from clinical practice

INTRODUCTION

With increased use of antiretroviral drugs (ARVs) in HIV uninfected persons, proper reporting on suspected unexpected serious adverse reactions (SUSARs) and continued insight into adverse drug reactions (ADRs) are needed for adequate information on safety of ARVs in such populations.

MATERIAL AND METHODS

Medical documentation of persons receiving ARVs after non-occupational HIV exposure (non-occupational post-exposure prophylaxis - nPEP) during 5 successive years (2009-2013) was evaluated by two HIV physicians. Adverse drug reactions s and SUSARs were defined according to international standards. In statistical analyses Cox proportional hazard models were used to identify independent predictors of developing a first ADR.

RESULTS

In total 375 persons received nPEP with the following indications: needle stick (43%), unprotected sexual intercourse (17%), rape (10%) and first aid (10%). In 84 (22%) cases the source patient was HIV positive or an active injecting drug user. In total 170 ADRs were reported. One hundred thirty-nine persons had only 1 ADR. The most frequent first ADRs were gastrointestinal disorders (22%), followed by general symptoms (9%), hypersensitivity reactions (1.6%) and CNS symptoms (1.3%). The remaining events represented less than 1% of all patients. Eight (2.1%) patients developed a SUSAR. In multivariate analyses only age at first visit to the clinic was an independent predictor of developing an ADR (HR = 1.17, 95% CI: 1.03-1.34; p = 0.02).

CONCLUSIONS

In our observations ADRs in reaction to nPEP were frequent yet usually mild events, mostly occurring in the first 2 weeks and rarely causing discontinuation. The only significant factor increasing the risk of ADR was age. SUSARs were rare, transient and clinically insignificant.

A randomized clinical trial comparing ritonavir-boosted lopinavir versus raltegravir each with tenofovir plus emtricitabine for post-exposure prophylaxis for HIV infection

OBJECTIVES

The objective of this study was to assess post-exposure prophylaxis (PEP) non-completion at day 28, comparing two regimens.

METHODS

A prospective, open, randomized clinical trial was conducted at a tertiary hospital in Barcelona, Spain. Individuals attending the emergency room because of potential sexual exposure to HIV were randomized to tenofovir disoproxil/emtricitabine (245/200 mg) plus either ritonavir-boosted lopinavir (400/100 mg) or raltegravir (400 mg). The primary endpoint was PEP non-completion at day 28. Secondary endpoints were adherence, adverse events and rate of seroconversions. This study was registered in ClinicalTrials.gov: NCT01576731.

RESULTS

One-hundred-and-twenty-one individuals were randomized to receive ritonavir-boosted lopinavir and 122 to raltegravir (n = 243). PEP non-completion at day 28 was 43% with no significant difference between arms. We performed a modified ITT analysis including only those patients who attended on day 1 (n = 191). PEP non-completion in this subgroup was higher in the ritonavir-boosted lopinavir arm than in the raltegravir arm (34.6% versus 20.4%, P = 0.04), as was the number of patients lost to follow-up at day 28 (32.6% versus 21.6%, P = 0.08) and the proportion of patients with low adherence (49.2% versus 30.8%, P = 0.03). Adverse events were significantly more common in the ritonavir-boosted lopinavir arm (73.4% versus 60.2%, P = 0.007). There was an HIV seroconversion at day 90 in the raltegravir arm in a patient who had multiple potential sexual risk exposures before and after receiving PEP.

CONCLUSIONS

Although we found no differences between arms regarding PEP non-completion, poor adherence and adverse events were significantly higher in patients allocated to tenofovir disoproxil/emtricitabine plus ritonavir-boosted lopinavir. These data support the use of raltegravir as the preferred third drug in current PEP recommendations.

Significant intolerability of efavirenz in HIV occupational postexposure prophylaxis

BACKGROUND

Completion of human immunodeficiency virus (HIV) occupational postexposure prophylaxis (PEP) is important for successful prophylaxis.

AIM

To determine factors associated with failure to complete the four-week HIV PEP.

METHODS

A retrospective study was conducted among healthcare workers (HCWs) accidentally exposed to blood or body fluids of patients at the Bamrasnaradura Infectious Diseases Institute, Thailand, between March 1996 and June 2014. Logistic regression analysis was used to determine factors associated with failure to complete the four-week HIV PEP.

FINDINGS

In total, 225 exposure episodes were reported. The mean age of HCWs was 33.1 (standard deviation 9.9) years, and 189 (84%) were female. Nurses (43%) were exposed most frequently. The HIV status of the source was defined in 149 (66%) episodes, and 101 (68%) of these were positive. Of 225 exposures, PEP was prescribed in 155 (69%) cases, with intentional discontinuation in 26 cases. Ninety-one of 129 (71%) HCWs completed the four-week regimen. Multi-variate analysis showed that a regimen of two nucleotide reverse transcriptase inhibitors (NRTI) + efavirenz (EFV) was the only significant factor associated with non-completion of the four-week course (odds ratio 37.8, 95% confidence interval 4.2-342.3; P < 0.01). Other factors including age, sex, staff position, status of the source and other PEP regimens were not associated with non-completion of the four-week course (P > 0.05). None of the HCWs were documented to have HIV seroconversion.

CONCLUSION

A regimen of two NRTIs + EFV was significantly associated with premature discontinuation of occupational PEP. This regimen should not be used for HIV prophylaxis following occupational exposure.

Postexposure management of healthcare personnel to infectious diseases

Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

Adherence to post-exposure prophylaxis for non-forcible sexual exposure to HIV: a systematic review and meta-analysis

To characterize adherence to post-exposure prophylaxis after non-forcible sexual exposure to HIV, we conducted a review of the literature and meta-analysis. Articles were considered if they contained primary adherence data following non-forcible sexual exposure. Random-effects meta-analysis was used to create pooled point estimates for adherence. Of 1,257 abstracts identified through our search algorithm, 17 were eligible for inclusion in this review, representing 3,634 patients enrolled in 3 randomized controlled trials (RCTs), 9 prospective and 5 retrospective observational studies. Pooled adherence, primarily assessed by self-report, was 77 % [95 % confidence interval (CI) 68-87] in prospective observational studies, 81 % (95 % CI 65-96) in retrospective studies, 78 % (95 % CI 65-91) in RCTs, and 78 % (95 % CI 72-85) overall. Overall adherence was moderately high, with high variability between studies. Assessment of adherence could be enhanced by the use of objective measurements.

Nonoccupational postexposure HIV prophylaxis in sexual assault programs: a survey of SANE and FNE program coordinators

This cross-sectional study describes sexual assault nurse examiner (SANE)/forensic nurse examiner (FNE) program practices related to HIV testing, nonoccupational postexposure prophylaxis (nPEP), and common barriers to offering HIV testing and nPEP. A convenience sample of 174 SANE/FNE programs in the United States and Canada was drawn from the International Association of Forensic Nurses database, and program coordinators completed Web-based surveys. Three fourths of programs had nPEP policies, 31% provided HIV testing, and 63% offered nPEP routinely or upon request. Using χ(2) and Fisher's exact tests, a greater proportion of Canadian programs had an nPEP protocol (p = .010), provided HIV testing (p = .004), and offered nPEP (p = .0001) than U.S.-based programs. Program coordinators rated providing pre- and/or posttest counseling and follow-up as the most important barrier to HIV testing, and medication costs as the most important barrier to providing nPEP. Our results indicate HIV-related services are offered inconsistently across SANE/FNE programs.

[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS

To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America.

RESULTS

cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis.

CONCLUSIONS

These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.

Early upper digestive tract side effects of zidovudine with tenofovir plus emtricitabine in West African adults with high CD4 counts

INTRODUCTION

Tenofovir (TDF) with emtricitabine (FTC) and zidovudine (ZDV) is a recognized alternate first-line antiretroviral (ART) regimen for patients who cannot start treatment with non-nucleoside reverse transcriptase inhibitors (NNRTIs). Clinical studies comparing TDF+FTC+ZDV to other regimens are lacking.

METHODS

Participants in a trial of early ART in Côte d'Ivoire (Temprano ANRS 12136) started treatment with TDF/FTC plus either efavirenz (EFV) or ZDV (HIV-1+2 dually infected patients and women refusing contraception or previously treated with nevirapine). We compared rates of upper digestive serious adverse events (sAEs) between TDF/FTC+EFV and TDF/FTC+ZDV patients during the first six months of treatment. sAEs were defined as either grade 3-4 AEs or persistent grade 1-2 AEs leading to drug discontinuation.

RESULTS

A total of 197 patients (76% women, median CD4 count 395/mm(3)) started therapy with TDF/FTC, 126 with EFV and 71 with ZDV. During the first six months of ART, 94 patients had digestive AEs (nausea/vomiting) of any grade (EFV 36/126, 29%; ZDV 58/71, 82%, p<0.0001), including 20 sAEs (EFV 3/126, 5%; ZDV 17/71, 24%, p<0.0001). In-patients on TDF/FTC+ZDV with digestive AEs, the median time to the first symptom was two days (IQR: 1-4). Plasma ZDV (Cmax) distributions and pill ZDV dosages were normal. Patients with digestive AEs had higher haemoglobin levels and tended to have higher body mass indices and more frequent past histories of cotrimoxazole (CTX) prophylaxis.

CONCLUSIONS

We observed an unexpectedly high rate of digestive sAEs in West African adults, mostly women, who started a 3-nuc ART with TDF/FTC+ZDV in Côte d'Ivoire. These adults were participating in a trial of early ART and had much higher CD4 counts than those who currently routinely start ART in sub-Saharan Africa. They all received CTX concomitantly with ZDV. We suggest that further early prescriptions of TDF+XTC+ZDV should be carefully monitored and that whenever possible, the rate of early upper digestive adverse events should be compared to that occurring in-patients taking other drug regimens.

CLINICAL TRIAL NUMBER

NCT00495651.

[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.

Evaluating counseling outcome on adherence to prophylaxis and follow-up after sexual HIV-risk exposure: a randomized controlled trial

OBJECTIVE

Post-exposure prophylaxis (PEP) is recommended for the management of sexual HIV-risk exposure. However, a high percentage of exposed patients discontinue both their 28-day prophylaxis course before 15 days and HIV testing follow-up before M3. The objective of this study is to assess the efficacy of a counseling intervention in enhancing both adherence to PEP and HIV testing follow-up.

METHODS

Between 1 June 2004 and 31 December 2005, 54 patients exposed to sexual HIV-risk exposure were included in a multicenter, prospective, controlled, randomized trial, comparing a group receiving a counseling intervention in addition to traditional medical management (intervention group (IG), n=28) vs. a control group (CG, n=26). Patients in the IG received interactive counseling interventions focused on adherence to PEP and to HIV testing follow-up, led by specially trained nurses. The main outcome measures were proportion of patients achieving 100% adherence to PEP as evaluated on D15 by a self-completed patient questionnaire and on HIV testing on D45 and M3.

RESULTS

Groups were well balanced at baseline for age, sex, and circumstances of exposure. The proportion of 100% adherent patients to PEP was significantly higher in the IG compared to the CG (54% vs. 23%, p=0.036). Patients in the IG were more likely to complete the HIV testing follow-up at D45 (86% vs. 54%, p=0.023) and M3 (68% vs. 38%, p=0.056).

CONCLUSIONS

This study suggests the effectiveness of a counseling program to enhance adherence to both PEP and HIV testing follow-up after sexual exposure.

Tolerability of HIV postexposure prophylaxis with tenofovir/emtricitabine and lopinavir/ritonavir tablet formulation

OBJECTIVE

To evaluate the tolerability of HIV postexposure prophylaxis (PEP) with tenofovir/emtricitabine and lopinavir/ritonavir tablet formulation (TDF/FTC+LPV/r).

DESIGN

Multicentric observational prospective study.

METHOD

Adults with an HIV transmission risk in the past 48 h were eligible. Baseline sociodemographic characteristics, description of exposure event, and HIV serostatus of the source patient were collected. Laboratory monitoring for toxicity and a clinical evaluation were performed; adherence and side effects were recorded using a standardized form on day 0, 15, and 28.

RESULTS

Between November 2006 and June 2008, 249 participants were included in 10 French hospitals. Mean age was 31.5 +/- years. Sex ratio male/female was 1.96. Exposure events are as follows: occupational exposure, 40 (16%); sexual intercourse, 204 (82%); and other, 5 (2%). Tolerability could be evaluated in 188 cases. In 22 cases, PEP was discontinued for adverse effects before day 28, including two cases of skin rash related to TDF/FTC prescription, one renal lithiasis related to LPV/r prescription, and one rhabdomyolysis. One hundred and sixty-six persons completed the 28 days of PEP with tolerability judged as good in 96 (58%) individuals. Among everyone who experienced at least one side effect, 78% reported diarrhea, 78% asthenia, and 59% nausea and/or vomiting.

CONCLUSION

Considering data of previous studies performed using similar methodology, the dropout rate due to adverse events appeared significantly lower in TDF/FTC+LPV/r tablet formulation than those in zidovudine/lamivudine (ZDV/3TC)+nelfinavir (P < 0.0001), ZDV/3TC+lopinavir/ritonavir soft gel capsules (P < 0.01), and 3TC+TDF+atazanavir boosted by ritonavir (P < 0.05) and should be considered as standard of care concerning HIV PEP.

The psychological consequences of occupational blood and body fluid exposure injuries

PURPOSE

This article describes the psychological impact of occupational blood and body fluid (BBF) exposure injuries and provides suggestions for improving clinical practice.

METHOD

A literature review was conducted to search for articles relating to the psychological consequences and management of these work injuries.

RESULTS

Acute psychological symptoms including posttraumatic stress, anxiety and depression are frequently experienced postexposure, which appear to be the major contributing factors of time loss from work. Furthermore, a subgroup is at risk for chronic symptoms and disability that persists beyond notification that no disease transmission occurred. Distressed workers often go unrecognised and untreated, and their assistance needs are largely unknown. Accordingly, this article draws upon the posttraumatic stress literature to offer suggestions for advancing the postexposure management of these injuries.

CONCLUSIONS

This clinical commentary underscores the serious yet understudied secondary psychological effects of occupational BBF exposure injuries. Postexposure management programmes need to place greater emphasis on psychosocial and educational initiatives to improve the identification and treatment of symptomatic workers.

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.

Postexposure prophylaxis: a guide for prevention of human immunodeficiency virus transmission in orthopedic surgery

Approximately half of orthopedic surgeons reported operating on at least 1 patient with known HIV infection. Knowledge of postexposure prophylaxis guidelines may prevent HIV transmission and avert unnecessary exposure to antiretroviral agents.