Prescription of Postexposure Prophylaxis for HIV-1 in the Emergency Room: Correct Transmission Risk Assessment Remains Challenging

Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Concordance of emergency department physicians' decisions on HIV post-exposure prophylaxis with national guidelines: results from a retrospective cohort study

BACKGROUND

Post-exposure prophylaxis (PEP) is an effective tool to prevent infection with HIV. Patients seeking PEP after potential HIV exposure usually present to the emergency department (ED). Our study sought to determine the concordance of ED physicians' decisions on HIV-PEP with national guidelines (primary objective) and to assess the clinical relevance of drug-drug interactions (DDIs) between the HIV-PEP regimen and patients' concomitant medication (secondary objective).

METHODS

We conducted a retrospective cohort study at the ED of Hannover Medical School, Germany. Between 1 January 2018 and 31 December 2019, 113 of 11 246 screened patients presented to the ED after potential HIV exposure and were enrolled in the study.

RESULTS

The median age of the patients (82.3% male) was 30 y (IQR 25-35.5), 85.8% of potential HIV exposures were characterised as sexual and 85.0% presented within 72 h. ED physicians' decisions on HIV-PEP were concordant with national guidelines in 93.8%. No clinically relevant DDIs were detected.

CONCLUSIONS

ED physicians' decisions on HIV-PEP were highly concordant with national guidelines. Approximately 1% of patient presentations to the ED were related to HIV exposure; therefore, training ED physicians on HIV transmission risk assessment and indications/contraindications for HIV-PEP is paramount.

Performance of HIV Infection Prediction Models in Men Who Have Sex with Men: A Systematic Review and Meta-Analysis

Effective ways to identify and predict men who have sex with men (MSM) at substantial risk for HIV is a global priority. HIV risk assessment tools can improve individual risk awareness and subsequent health-seeking actions. We sought to identify and characterize the performance of HIV infection risk prediction models in MSM through systematic review and meta-analysis. PubMed, Embase, and The Cochrane Library were searched. Eighteen HIV infection risk assessment models with a total of 151,422 participants and 3643 HIV cases were identified, eight of which have been externally validated by at least one study (HIRI-MSM, Menza Score, SDET Score, Li Model, DHRS, Amsterdam Score, SexPro model, and UMRSS). The number of predictor variables in each model ranged from three to 12, age, the number of male sexual partners, unprotected receptive anal intercourse, recreational drug usage (amphetamines, poppers), and sexually transmitted infections were critical scoring variables. All eight externally validated models performed well in terms of discrimination, with the pooled area under the receiver operating characteristic curve (AUC) ranging from 0.62 (95%CI: 0.51 to 0.73, SDET Score) to 0.83 (95%CI: 0.48 to 0.99, Amsterdam Score). Calibration performance was only reported in 10 studies (35.7%, 10/28). The HIV infection risk prediction models showed moderate-to-good discrimination performance. Validation of prediction models across different geographic and ethnic environments is needed to ensure their real-world application.

Assessment of HIV-postexposure prophylaxis prescription quality after a training programme and assistance in decisions provided by a computer-based decision program: a cross-over study

BACKGROUND

Among the tools for preventing HIV transmission, post-exposureprophylaxis (PEP) is an effective means after potential HIV exposure.

OBJECTIVES

To evaluate aPEP training program and acomputer-baseddecision program (CBDP) using simulated patients in emergency department (ED) on the quality of PEP prescription.

METHODS

This cross-overstudy, carried out from 7January2019 to 28June2019, included 20 ED physicians from 10 tertiary referral hospitals. Intervention consisted of two parts: Period Aassessed physicians' compliance with PEP prescription guidelines before and after atraining program, using 400 post-exposuremedical records (200 occupational and 200 non-occupational). Period Bconsisted of arandomized crossover study involving 40 simulated patients, with physicians using or not using aCBDP. Sensitivity, specificity, and accuracy of PEP prescription in accordance with the guidelines were assessed.

RESULTS

In period A, alpha Cronbach was less than 0.7 whereas it increased after the training to be >0.7. Sensitivity increased, especially for occupational patients ranging from 51.8%-66.6% to 70.4%-90.1%, whereas specificity increased for non-occupationalpatients ranging from 15.5%-51.9% to 52.1%-75.3%. In period B, sensitivity, specificity, and rate of complete assessments significantly increased (p < 0.0001) after the initiation of CBDP. Rate of PEP prescription significantly decreased (p < 0.001) for all subcategories.

CONCLUSION

Significant recommendations-discordantprescriptions, mainly overprescription, occurred for patients visiting ED for PEP. Training improved quality of PEP prescription but the reduction was modest. The availability of CBDP improved quality of PEP prescription and allowed for better data collection and reduction of PEP prescription.

Context and Barriers to the Prescription of Nonoccupational Postexposure Prophylaxis Among HIV Medical Care Providers: National Internet-Based Observational Study in China

BACKGROUND

Nonoccupational postexposure prophylaxis (nPEP) is an effective HIV biomedical prevention strategy. The research and use of nPEP are mainly concentrated in the developed world, while little is known about the knowledge, attitudes, and practices of nPEP among HIV medical care providers in developing countries.

OBJECTIVE

We aimed to assess the nPEP knowledge and prescribing practice among HIV medical care providers in mainland China.

METHODS

HIV medical care providers were recruited in China during May and June 2019 through an online survey regarding nPEP-related knowledge, attitudes, and clinical prescription experiences. Multivariable logistic regression was performed to identify factors associated with prescribing nPEP among HIV medical care providers.

RESULTS

A total of 777 eligible participants participated in this study from 133 cities in 31 provinces in China. Of the participants, 60.2% (468/777) were unfamiliar with nPEP and only 53.3% (414/777) of participants ever prescribed nPEP. HIV care providers who worked in a specialized infectious disease hospital (vs general hospital, adjusted odds ratio [aOR] 2.49; 95% CI 1.85-3.37), had practiced for 6-10 years (vs 5 or fewer years, aOR 3.28; 95% CI 2.23-4.80), had practiced for 11 years or more (vs 5 or fewer years, aOR 3.75; 95% CI 2.59-5.45), and had previously prescribed occupational PEP (oPEP, aOR 4.90; 95% CI 3.29-7.29) had a significantly positive association with prescribing nPEP. However, unfamiliarity with nPEP (aOR 0.08; 95% CI 0.05-0.11), believing nPEP may promote HIV high-risk behavior (aOR 0.53; 95% CI 0.36-0.77) or result in HIV drug resistance (aOR 0.53; 95% CI 0.36-0.77) among key populations, and self-reported having no written oPEP guideline in place (aOR 0.53; 95% CI 0.35-0.79) were negatively associated with nPEP prescription behavior.

CONCLUSIONS

HIV medical care providers have insufficient nPEP knowledge and an inadequate proportion of prescribing, which may impede the scale-up of nPEP services to curb HIV acquisition. The implementation of tailored nPEP training or retraining to HIV medical care providers would improve this situation.

Data linkage to evaluate the long-term risk of HIV infection in individuals seeking post-exposure prophylaxis

Evidence on the long-term risk of HIV infection in individuals taking HIV post-exposure prophylaxis remains limited. In this retrospective data linkage study, we evaluate the occurrence of HIV infection in 975 individuals who sought post-exposure prophylaxis in a tertiary hospital between 2007 and 2013. Using privacy preserving probabilistic linkage, we link these 975 records with two observational databases providing data on HIV events (Zurich Primary HIV Infection study and the Swiss HIV Cohort Study). This enables us to identify 22 HIV infections and to obtain long-term follow-up data, which reveal a median of 4.1 years between consultation for post-exposure prophylaxis and HIV diagnosis. Even though men who have sex with men constitute only 35.8% of those seeking post-exposure prophylaxis, all 22 events occur in this subgroup. These findings should strongly encourage early consideration of pre-exposure prophylaxis in men who have sex with men after a first episode of post-exposure prophylaxis.

Individuals seeking post-exposure prophylaxis (PEP) for HIV may represent an important risk group for future HIV infection. Here the authors find HIV infections at long-term follow-up in 22 of 348 men who have sex with men, and 0 of 623 other PEP seekers.

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.

To prescribe, or not to prescribe: decision making in HIV-1 post-exposure prophylaxis

OBJECTIVES

We investigated the trend in usage of post-exposure prophylaxis (PEP) after HIV-1 risk exposure and evaluated PEP prescription decision making of physicians according to guidelines.

METHODS

All PEP consultations from January 2014 to December 2016 in patients presenting at the University Hospital of Cologne (Germany) were retrospectively analysed. HIV risk contacts included sexual and occupational exposure. The European AIDS Clinical Society (EACS) Guidelines for HIV PEP (version 9.0, 2017) were used for assessment.

RESULTS

A total of 649 patients presented at the emergency department (ED) or the clinic for infectious diseases (IDC) for PEP consultations. A continuous increase in the number of PEP requests was recorded: 189 in 2014, 208 in 2015 and 252 in 2016. PEP consultations in men who have sex with men (MSM) showed a remarkable increase in 2016 (2014, n = 96; 2015, n = 101; 2016, n = 152). Decisions taken by physicians with a specialization in infectious diseases (n = 547) included 61 (11%) guideline-discordant prescriptions [2014: 14% (n = 22); 2015: 9% (n = 16); 2016: 11% (n = 23)]. Among these, sexual exposure accounted for 45 (74%) cases, including 15 cases of nonconsensual sex, while occupational exposure accounted for 14 (23%) cases and other exposure two cases (3%). The main reason for guideline-discordant PEP prescriptions was emotional stress of the patient (n = 37/61).

CONCLUSIONS

PEP prescriptions are increasing and decision making is influenced by patients' emotional stress, but PEP prescriptions should be strictly administered according to risk assessment.