Postexposure Prophylaxis Against Human Immunodeficiency Virus (HIV): New Guidelines From the WHO: A Perspective

Pharmacokinetics, the Immunological Impact, and the Effect on HIV Ex-Vivo Infectivity of Maraviroc, Raltegravir, and Lopinavir in Men Who Have Sex with Men Using Postexposure Prophylaxis

Most of the studies using the colorectal tissue explants challenge model have been conducted after one single dose and before reaching a steady state. We consider that longer exposure as in 28-day postexposure prophylaxis (PEP) course and in an at-risk setting, such as after a sexual risk exposure to HIV could give us valuable information about these drugs. In a substudy we assessed pharmacokinetics, changes on immune system and ex-vivo rectal mucosal susceptibility to HIV-1 infection after taking maraviroc (MVC), raltegravir (RAL), and ritonavir-boosted lopinavir (LPV/r) PEP-based regimens in 30 men who have sex with men. Participants received 28 days of twice-daily MVC (n = 11), RAL (n = 10) or LPV/r (n = 9) all with tenofovir/emtricitabine (TDF/FTC) backbone. Blood, rectal fluid, and rectal tissue samples were collected at days 7, 28, and 90 after starting PEP. The samples obtained at day 90 were considered baseline. All studied antiretrovirals were quantifiable at 7 and 28 days in all tissues. Activation markers were increased in CD4 mucosal mononuclear cells (MMCs) after 28 days of MVC: CD38 + 68.5 versus 85.1, p = .008 and CD38+DR +16.1 versus 26.7, p = .008. Exposure to MVC at both endpoints (7 and 28 days) was associated with significant suppression of HIV-1BAL (p = .005 and p = .028), but we did not observe this effect with RAL or LPV/r. Merging together changes in MMC in all arms, we found a positive correlation in the CD8 T cell lineage between the infectivity at day 7 and activation (CD38+ r = 0.43, p = .025, DR + r = 0.547, p = .003 and 38+DR+ r = 0.526, p = .05), senescence (CD57+CD28- r = 0.479, p = .012), naive cells (RA+CCR7+ r = 0.484, p = .01), and CCR5 expression (r = 0.593, p = .001). We conclude that MVC in combination with TDF/FTC was associated with viral suppression in rectal explants and that overall ex-vivo HIV infectivity correlated with activation and senescence in CD8 MMCs.

Learning from combination HIV prevention programmes to face COVID-19 emerging pandemic

Before a vaccine against SARS-CoV-2 became available, several measures to control COVID-19 pandemic are necessary. Analogously, in the absence of an available vaccine, Combination HIV Prevention Programmes have consolidated a large experience of biomedical, behavioral and structural interventions suitable for several epidemiological settings. Adaptation of such experiences can organize mid-term and long-term responses to face COVID-19.

Thematic synthesis HIV prevention qualitative studies in men who have sex with men (MSM)

BACKGROUND

Qualitative studies on HIV prevention strategies and methods among men who have sex with men (MSM) allow identify knowledge gaps and improve preventive actions.

OBJECTIVE

To make a thematic synthesis of the scientific productions that use the qualitative methodology in the strategies and methods of HIV prevention area among MSM.

METHODS

We conducted a literature review following the guidelines of the ENTREQ protocol. The analysis included 48 empirical studies published in Portuguese, English and Spanish between 2001 and 2018 available in the Medline, Embase, Scielo, Scopus, Bireme and Web of Science databases.

RESULTS

Where an increased production in the last six years and concentration in northern countries. Seven prevention methods were part of the study, with emphasis on pre-exposure prophylaxis, testing, condoms and behavioral strategies. The main topics discussed were stigma and support and care networks.

CONCLUSION

we notice that an increasing production on prevention in the men who have sex with men segment results from the emergence of multiple preventive methods and strategies and their combined actions beyond the star role of condoms.

HDV/AIDS awareness among young people and their sexual behaviour

This article presents the results of a survey carried out among 1,427 Novosibirsk university students (medical, engineering and humanities specializations) with the purpose of assessing their awareness concerning the prevention of HIV and STIs, as well as risky sexual behaviour. The level of knowledge about HIV is shown to be rather high among Novosibirsk university students. However, an insufficient level of awareness concerning rare HIV transmission routes is identified. In addition, the respondents are found to adhere to out-of-date views concerning HIV patients. Female respondents in this age group tend to trust their regular partner, thus neglecting preventive measures. More than half of the respondents have a positive attitude towards using a condom during sexual intercourse.

Management of Human Immunodeficiency Virus in the Emergency Department

Over the past 30 years, significant advances have transformed the landscape of human immunodeficiency virus (HIV) care in the emergency department. Diagnosis and management of HIV has improved, resulting in a decline in the incidence of acquired immunodeficiency syndrome (AIDS)-defining infections. Advances in pharmacology have led to fewer serious medication toxicities and more tolerable regimens. Emergency providers have played an increasingly important role in HIV screening and diagnosis of acute infection. Provision of postexposure prophylaxis is expanding from a focus on occupational exposure to include all high-risk cases.

Tackling HIV and AIDS: contributions by non-human primate models

During the past three decades, non-human primate (NHP) models have gained an increasing importance in HIV basic and translational research. In contrast to natural host models, infection of macaques with virulent simian or simian-human immunodeficiency viruses (SIV, SHIV) results in a disease that closely resembles HIV infection and AIDS. Although there is no perfect animal model, and each of the available models has its benefits and limitations, carefully designed NHP studies with selection of experimental variables have unraveled important questions of basic pathogenesis and have provided the tools to explore and screen intervention strategies. For example, NHP studies have advanced our understanding of the crucial events during early infection, and have provided proof-of-concept of antiretroviral drug treatment and prevention strategies such as pre-exposure prophylaxis (PrEP) regimes that are increasingly used worldwide, and upon overcoming further barriers of implementation, have the potential to make the next generation AIDS-free. Remaining goals include the pursuit of an effective HIV vaccine, and HIV cure strategies that would allow HIV-infected people to ultimately stop taking antiretroviral drugs. Through a reiterative process with feed-back from results of human studies, NHP models can be further validated and strengthened to advance our scientific knowledge and guide clinical trials.

Otitis Media in Fully Vaccinated Preschool Children in the Pneumococcal Conjugate Vaccine Era

Objectives. To evaluate the effect of pneumococcal conjugate vaccine (PCV13) on the burden of acute otitis media (AOM) and to evaluate the characteristics of AOM versus otitis media with effusion (OME) in the 2 PCV periods. Methods. A cohort of fully vaccinated children aged 18 to 60 months diagnosed with AOM from 2006 to 2015 was identified. Patients with otorrhea/bulging tympanic membrane were considered as true AOM, while those without bulging/otorrhea were considered to have OME. Burden of true AOM in the PCV7 and PCV13 periods and clinical features of true AOM versus OME were compared. Results. Of 393 episodes in our cohort, 50.8% occurred in PCV7 period. Burden of true AOM in the 2 PCV groups was similar: 26% in PCV7 versus 26.4% in PCV13 (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.65-1.60). Factors significantly associated with OME were cold season (OR = 1.54, 95% CI = 1.04-2.4), fever (OR = 2.05, 95% CI = 1.29-3.3), and recurrence (OR = 2.24, 95% CI = 1.22-4.09). No complications of AOM were identified. Majority episodes were treated with antibiotics. Conclusion. Unlike the role of PCV13 in reducing invasive pneumococcal disease, its effect on reducing the burden of AOM is minimal as compared with PCV7. With regard to characteristics of AOM versus OME, findings of tympanic membrane should be used to suggest a diagnosis of AOM, instead of occurrence of fever or recurrence of AOM episodes. Using this approach would help in guiding the use of antibiotics appropriately.

What is the benefit of the biomedical and behavioral interventions in preventing HIV transmission?

INTRODUCTION

Scientific evidence supports the synergy between biomedical and behavioral interventions aimed at preventing the transmission of HIV as a strategy to eradicate AIDS.

OBJECTIVE

To characterize comparatively the benefits from biomedical and behavioral interventions to prevent HIV transmission.

METHODS

Narrative review. We performed a comparative analysis of the benefits of studied interventions by means of estimating the number needed to treat (NNT). Evaluated interventions: counseling activities for behavior change to prevent exposure to HIV; antiretroviral pre-exposure prophylaxis (PrEP) and antiretroviral post-exposure prophylasis (PEP) for HIV and treatment of serodiscordant couples as a strategy for prevention of HIV transmission (TasP).

RESULTS

counseling interventions and TasP have smaller NNTs, equal to, respectively, 11 (95%CI 9 - 18) at 12 months and 34 (95%CI 23 - 54) in 42 months comparatively to PrEP interventions, that resulted in 41 (95%CI 28 - 67) individuals receiving antiretrovirals in order to prevent one case of HIV infection at 36 months for men and serodiscordant couples. PEP interventions are associated with protective effects estimated at 81%. Lack of trials evaluating PEP prevents estimate of NNT.

CONCLUSION

The estimate of the NNT can be a helpful parameter in the comparison between the effectiveness of different behavioral and biomedical HIV prevention strategies. Studies evaluating the benefit and safety of combined behavioral and biomedical interventions are needed, especially considering the attributable fraction of each component. Integration of behavioral and biomedical interventions is required to achieve complete suppression of the virus, and thus reducing viral replication, infectivity and the number of cases.

Panel 6: Vaccines

Objective To review the literature on progress regarding (1) effectiveness of vaccines for prevention of otitis media (OM) and (2) development of vaccine antigens for OM bacterial and viral pathogens. Data Sources PubMed database of the National Library of Science. Review Methods We performed literature searches in PubMed for OM pathogens and candidate vaccine antigens, and we restricted the searches to articles in English that were published between July 2011 and June 2015. Panel members reviewed literature in their area of expertise. Conclusions Pneumococcal conjugate vaccines (PCVs) are somewhat effective for the prevention of pneumococcal OM, recurrent OM, OM visits, and tympanostomy tube insertions. Widespread use of PCVs has been associated with shifts in pneumococcal serotypes and bacterial pathogens associated with OM, diminishing PCV effectiveness against AOM. The 10-valent pneumococcal vaccine containing Haemophilus influenzae protein D (PHiD-CV) is effective for pneumococcal OM, but results from studies describing the potential impact on OM due to H influenzae have been inconsistent. Progress in vaccine development for H influenzae, Moraxella catarrhalis, and OM-associated respiratory viruses has been limited. Additional research is needed to extend vaccine protection to additional pneumococcal serotypes and other otopathogens. There are likely to be licensure challenges for protein-based vaccines, and data on correlates of protection for OM vaccine antigens are urgently needed. Implications for Practice OM continues to be a significant health care burden globally. Prevention is preferable to treatment, and vaccine development remains an important goal. As a polymicrobial disease, OM poses significant but not insurmountable challenges for vaccine development.

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.

Evolving pneumococcal serotypes and sequence types in relation to high antibiotic stress and conditional pneumococcal immunization

In Taiwan, beginning in 2013, the 13-valent pneumococcal conjugate vaccine (PCV13) was provided free of charge to children 2–5 years of age. In 2014, this was extended to children 1–5 years old. During 2012–2014, 953 cases of culture-confirmed pneumococcal disease (CCPD), including 104 invasive pneumococcal disease (IPD), were prospectively identified and analyzed at a 3,700-bed hospital in Taiwan. From 2012 to 2014, the incidence per 10,000 admissions decreased from 26.7 to 20.4 for CCPD (P < 0.001) and from 3.2 to 1.9 for IPD (P < 0.05). Significant reduction of PCV13 serotypes was firstly noted in children in 2013 and extended to both paediatric and adult populations in 2014. Simultaneously, the incidence per 10,000 admissions of non-PCV13 serotypes increased from 6.1 in 2012 to 9.3 in 2014 (P < 0.005). The most prevalent non-PCV13 serotypes were 15A, 15B, and 23A, each containing a predominant clone, ST63^15A, ST83^15B, and ST338^23A. From 2012 to 2014, isolates with penicillin minimum inhibitory concentrations >2 mg/L decreased from 27.8% to 8.1% (P < 0.001) among all isolates. PCV13 immunization in young children demonstrated an early protective effect in all ages. However, in the elderly, the effect was compromised by an emergence of non-PCV13 serotypes.

Direct and indirect effects of the 13-valent pneumococcal conjugate vaccine administered to infants and young children

This paper analyzes the most recent reports regarding the direct and indirect effects of the 13-valent pneumococcal conjugate vaccine (PCV13) when administered to infants and young children. PCV13 extends the protective effects reported for the 7-valent pneumococcal conjugate vaccine (PCV7). A further reduction in the incidence of invasive pneumococcal disease, community-acquired pneumonia, acute otitis media, rhinosinusitis and carriage of PCV13 serotypes in vaccinated and unvaccinated subjects was found with PCV13 compared with PCV7. However, further studies are required to establish the effectiveness of PCV13 against serotypes 1, 5 and 3, the role of cross-protective antibodies evoked by serotype 6A on serotype 6C and the importance of the serotype replacement phenomenon following the extension of PCV13 use.