Nonoccupational HIV post-exposure prophylaxis: a 10-year retrospective analysis

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.

An open-label evaluation of safety and tolerability of coformulated bictegravir/emtricitabine/tenofovir alafenamide for post-exposure prophylaxis following potential exposure to human immunodeficiency virus-1

BACKGROUND

Single-tablet regimen (STR) provides a convenient once-daily regimen for the prevention of human immunodeficiency virus (HIV) infection. Here, we investigated the safety and tolerability of coformulated bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) as a three-drug, STR for post-exposure prophylaxis (PEP) in Chinese individuals.

METHODS

This was a prospective, open-label, single-arm trial conducted in a sexually transmitted diseases and acquired immunodeficiency syndrome clinic of a tertiary hospital in Beijing, China. Adults requiring PEP were prescribed BIC/FTC/TAF one pill once a day for 28 days. Clinical and laboratory data were collected and analyzed at baseline, weeks 2, 4, 8, 12, and 24.

RESULTS

Of 112 participants enrolled in the study, 109 (97.3%) were male and the mean age was 30 ± 8 years. PEP completion was 96.4% (95% confidence interval: 91.1-99.0%). Two participants stopped PEP after 2 days because the source partner was identified as HIV uninfected. One participant was excluded due to hepatitis B virus infection according to the exclusion criteria. One discontinued due to the participant's decision. No participant acquired HIV through week 24. Adherence was 98.9% (standard deviation [SD]: 3.3%) by self-reporting and 98.5% (SD: 3.5%) by pill count. Only five participants experienced mild clinical adverse events attributed to the study drug (including headache, diarrhea, and nausea) and four participants had elevated serum creatinine (grade 1).

CONCLUSIONS

A once daily, STR of BIC/FTC/TAF used as PEP was safe and well-tolerated with a high rate of completion and adherence in Chinese. BIC/FTC/TAF may be a good option for PEP.

TRIAL REGISTRATION

ChiCTR.org.cn, ChiCTR2100048080.

nPEP protocol implementation and evaluation at a local US Crisis Center

Non-occupational Post-Exposure Prophylaxis for HIV (nPEP) is recommended by the CDC for isolated exposures that pose "substantial risk" for HIV transmission. To combat multiple barriers to nPEP utilization, a comprehensive program was developed through the local community sexual assault provider. The purpose of this study was to evaluate nPEP protocol implementation. A retrospective chart review was conducted of all sexual assault victims seen during a six-month period, and all patients who accepted nPEP were selected for follow-up phone interviews. 157 patients presented during the study period. Mean time to care was 32.4hrs, with 126/157 (80%) presenting ≤72hrs. 114/157 (73%) patients were offered nPEP by providers. 67/114 (59%) patients accepted, with the most common reason for declining being needing more time to decide. 10/13 (77%) patients able to be contacted reported completing nPEP, with side-effects cited as the most common noncompletion reason. 9 reported side effects and 4 received recommended follow-up HIV testing. 83/99 (84%) patients clearly eligible by chart review were offered nPEP, suggesting good adherence to CDC guidelines. Most patients contacted completed nPEP despite side-effects, suggesting good adherence. Our findings demonstrated multiple points status post-sexual assault to potentially improve the nPEP process.

Drug users' awareness of and willingness to use HIV non-occupational post-exposure prophylaxis (nPEP) services in China: a mixed methods study

Background

Drug users are regarded as a high-risk population for HIV infection. Non-occupational post-exposure prophylaxis (nPEP) is internationally regarded as an effective biomedical prevention against HIV but still a small-scale pilot project in China at present. The aim of this study was to understand drug users’ awareness of and willingness to use nPEP service in China.

Methods

This mixed methods study consisting of a qualitative study and a cross-sectional survey was conducted in two cities of China from 2018 to 2019. The in-depth interviews were audio-taped, transcribed verbatim and analyzed using thematic framework analysis. Univariate and multivariate logistic regressions were used to examine factors associated with drug users’ awareness of and willingness to use nPEP.

Results

There were 401 and 19 participants included in quantitative and qualitative study respectively. Among participants in quantitative study, 30.2% had heard of nPEP and 56.7% reported willingness to use nPEP in future HIV exposure. In multivariate analyses, nPEP awareness was associated with age, sex, education level, AIDS knowledge score and HIV risk perception. nPEP willingness was associated with AIDS knowledge score, HIV risk perception, alcohol use, monthly income and awareness of nPEP. The qualitative results showed the barriers to nPEP willingness included the fatigue after taking drugs, high cost and side effects of nPEP medication, long nPEP course, and fear of privacy disclosure.

Conclusion

Drug users had low nPEP awareness and only about half participants reported willingness to use nPEP. It is essential to promote nPEP education campaigns among drug users, especially for elders, women and those with lower education level. Simultaneously, price regulation, side effect management, psychological support and privacy protection need to be managed well when nPEP is routinized.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07106-x.

Pre and Post-exposure Prophylaxis Awareness and Acceptability Among Sex Workers in Jamaica: A Cross-Sectional Study

The HIV prevention cascade is understudied among sex workers in Jamaica, where sex work and same sex practices are criminalized. We implemented a cross-sectional survey with cisgender women, transgender women, and cisgender men sex workers in Jamaica. We conducted multivariable logistic regression analyses to identify factors associated with PrEP and PEP awareness and acceptability. Participants (n = 340) included cisgender men (n = 124), transgender women (n = 101), and cisgender women (n = 115). PEP awareness was low (33.2%), yet acceptability was high (70.8%). In multivariable analyses, recent sexual violence, recent client violence, and sex work social cohesion were associated with PEP awareness and acceptability. One-third (32.7%) reported PrEP awareness, with high acceptability (80.2%). Relationship status and recent physical violence were associated with PrEP awareness and acceptability. In multivariable analyses, gender identity was not associated with differences in PEP/PrEP awareness/acceptability. Findings highlight the need to increase PEP and PrEP awareness and access among sex workers in Jamaica.

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.

HIV non-occupational postexposure prophylaxis (nPEP) usage among five key populations in China

OBJECTIVES

To examine the feasibility of non-occupational postexposure prophylaxis (nPEP) as a national strategy for HIV prevention in China, we investigated nPEP usage and related sociodemographic and behavioural factors among five key populations at high risk of contracting HIV.

METHODS

We conducted a cross-sectional study among five key populations from November 2018 to September 2019 in China using convenience sampling to recruit participants aged ≥18 years, self-reporting HIV status as either negative or unknown and providing written informed consent. Univariable and multivariable logistic regression models were fitted.

RESULTS

Our analysis included data from 2022 participants with a mean age of 35 years (SD=11.62). Only 57 (2.82%) participants had ever used nPEP. Sociodemographic and behavioural factors related to nPEP usage included populations (p<0.0001), age (p<0.05), education (p<0.05), nPEP knowledge (p<0.01), receiving conventional HIV prevention services (p<0.05) and HIV testing (p<0.05). A significant percentage (26%) of nPEP users used nPEP medication more than once. Challenges and concerns, such as multiple use of nPEP and syndemic conditions, were emerging.

CONCLUSIONS

Key populations in China had low nPEP usage rates. Female sex workers, people who use drugs, older and illiterate individuals with poor nPEP knowledge, not using HIV prevention services or never tested for HIV should be emphasised. Implementing nPEP services would be an important way to access high-risk individuals for intensive and tailored HIV prevention and intervention. Challenges of providing nPEP services and future study foci are highlighted.

Nonoccupational post-exposure prophylaxis for HIV after sexual intercourse among women in Brazil: Risk profiles and predictors of loss to follow-up

Access to antiretroviral-based HIV prevention has been marked by sex asymmetries, and its effectiveness has been compromised by low clinical follow-up rates. We investigated risk profiles of women who received nonoccupational post-exposure prophylaxis (nPEP), as well as the rates and predictive factors of loss to follow-up after nPEP initiation.Retrospective study evaluating 501 women who received nPEP between 2014 and 2015 at 5 HIV centers (testing centers-VCT, outpatient clinics, and infectious diseases hospital). Risk profiles were drawn based on the characteristics of the women and their sexual partners, and then stratified by sociodemographic indicators and previous use of HIV prevention services. Loss to follow-up (LTFU) was defined as not presenting for follow-up visits or for HIV testing after nPEP initiation. Predictors of LTFU were analyzed by calculating adjusted prevalence ratios (aPRs).Approximately 90% of women had sexual encounters that met the criteria established in the Brazilian guidelines for nPEP. Those who declared to be sex workers (26.5%) or drug users (19.2%) had the highest social vulnerability indicators. In contrast, women who had intercourse with casual partners of unknown HIV risk (42.7%) had higher education and less experience with previous HIV testing (89.3%) or nPEP use (98.6%). Of the women who received nPEP after sexual intercourse with stable partners, 75.8% had HIV-infected partners. LTFU rate was 72.8% and predictors included being Black (aPR = 1.15, 95% confidence interval [CI]: 1.03-1.30), using drugs/alcohol (aPR = 1.15, 95% CI: 1.01-1.32) and having received nPEP at an HIV outpatient clinic (aPR = 1.35, 95% CI: 1.20-1.51) or at an infectious diseases hospital (aPR = 1.37, 95% CI: 1.11-1.69) compared with a VCT. The risk of LTFU declined as age increased (aPR 41-59 years = 0.80, 95% CI: 0.68-0.96).Most women who used nPEP had higher socioeconomic status and were not part of populations most affected by HIV. In contrast, factors that contribute to loss to follow-up were: having increased social vulnerability; increased vulnerability to HIV infection; and seeking nPEP at HIV treatment services as opposed to at a VCT.

HIV Non-Occupational Post Exposure Prophylaxis in Nigeria: A Systematic Review of Research Evidence and Practice

BACKGROUND

Although non-occupational Human Immunodeficiency Virus (HIV) post-exposure prophylaxis (nPEP) has been proven to be efficacious in preventing HIV, it remains an underutilized prevention strategy in Nigeria. We aimed to conduct an overview of research studies on nPEP and practice in Nigeria from 2002 to 2018 examining: sociodemographic characteristics of study sample, awareness, knowledge and prior use of nPEP, reasons for HIV nPEP, timeliness in presenting for PEP, antiretrovirals (ARVs) used for nPEP, side effects and adherence, monitoring and follow-up visits, adherence to guidelines and recommendations for nPEP by healthcare institutions and the strength of evidence of reviewed studies.

METHODS

An electronic search on PubMed, PubMed Central (PMC), cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, Medline, Embase and Google Scholar for published studies on nPEP from January 2002 to December 2018. We conducted our search using different combinations of the keywords "HIV," "non-occupational," "nonoccupational," "post-exposure," "postexposure," "prophylaxis" and "Nigeria."

RESULTS

Five articles met the inclusion criteria for this study. About 25.4% of college students were aware of PEP.PEP awareness was significantly determined by the following factors ever tested for HIV, nude picture exchanges, sex without condom, and knowledge of partner's HIV status. Across studies, exposed victims who presented for PEP were mostly females (64%-78%). Rape was the most frequently occurring reason for seeking nPEP (25.9%-64.1%). Although most patients presented for nPEP within 72 hours, follow up visits were generally low (0%-2%) across studies assessed, except for one study that reported a high follow up visit of 83.3%. Guidelines adherence by healthcare institutions could not be established due to lack of information on key variables.

CONCLUSION

Our study highlights the paucity of research evidence on nPEP use in Nigeria, the societal and cultural contexts in which non-occupational exposures occur, healthcare providers' roles and the public health and practice implications.

Non-Occupational HIV Post-exposure Prophylaxis: A 10-Year Retrospective Review of Data Following Sexual Exposure From Yaounde Central Hospital, Cameroon

BACKGROUND

Human Immunodeficiency Virus (HIV) post exposure prophylaxis (PEP) consists of administering antiretroviral therapy within 72 hours of viral exposure and continued for four weeks. PEP has been shown to be an important means of preventing and decreasing the number of new HIV infections in the general population. The purpose of this study was to describe the profile of patients who consulted at the HIV/AIDS Care and Treatment Center of the Yaounde Central Hospital (YCH) for PEP following non-occupational exposure to HIV. To attain our objective, we carried out a 10-year retrospective review of patient records of all persons who consulted for accidental HIV exposure at the YCH, Cameroon.

METHODS

This study was an observational, retrospective analysis of hospital records of persons who consulted for PEP following accidental exposure to HIV in the outpatient HIV clinic at YCH between January 2007 and December 2016. Data extracted from patients' records were: type of HIV exposure, sex, age, profession, level of education, HIV status of source and time to consultation. Descriptive and inferential statistics were analyzed using STATA IC 12.0. Results were presented as median and interquartile range for continuous variables. Categorical variables were expressed as frequencies and proportions.

RESULTS

There were 628 consultations for PEP of which 48% (299/628) were as a result of non-occupational post exposure prophylaxis (nPEP). Of those who consulted for HIV PEP following non-occupational exposure, 78% (234/299) were females; adolescents group (15-19 years) and young adults group (20 - 24yrs.) constituted 41% (125/299). Forty percent (1208/299) were secondary or high school students (level of education) and 88% (262/299) were non-healthcare workers. The median time-to-consultation for non-occupational PEP (nPEP) was 19 hours (IQR: 12.4-25.0) and HIV status of the source was unknown in 64% (191/299) of cases and positive for 8% (25/299) of cases. The most frequent indications for consulting were sexual assault, 75% (224/299); condom slippage or breakage, 10% (30/299); and unprotected consensual sexual intercourse, 15% (45/299).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Consultations for nPEP are as frequent as those occupational PEP (48% vs 52% in this study) in clinical practice at YCH. A good history of the source is important as it prevents unnecessary prescriptions of ART (which themselves have potential side effects) for persons consulting for potential HIV non-occupational exposure. In our study, we found that 27% (82/299) unnecessary ART prescriptions were avoided by determining that the exposure source person had negative HIV status. In addition, adolescent or young females consulting for nPEP in clinics could be potential victims of sexual assault or gender-based violence. Where possible, we recommend that clinicians consider the source of suspected viral exposure in clinical practice prior to administering ART for PEP.

What is the extent of repeat prescriptions for post-exposure prophylaxis for HIV after sexual exposure among men who have sex with men in the UK?

People who repeatedly present for post-exposure prophylaxis (PEP) for prevention of HIV following a high-risk sexual exposure are of concern according to the British HIV Association PEP guidelines. The aim of this audit was to determine the extent of repeat PEP prescriptions for men who have sex with men (MSM) by conducting a retrospective review of patient notes from a 5-year period at one genitourinary medicine clinic. Over the 5 years, 107 of 929 MSM (11.5%; 95% confidence interval: 9.45-13.55) received more than one PEP prescription (repeat range 1-8; mean=3.3, s.d.=1.44). Forty percent of these had received three or more PEP prescriptions. Seven of the 107 became HIV positive. Patients need to be offered and encouraged to take up behavioural risk reduction interventions at the time of each PEP prescription.

Sex, human rights and AIDS: an analysis of new technologies for HIV prevention in the Brazilian context

Worldwide, HIV prevention is challenged to change because clinical trials show the protective effect of technologies such as circumcision, preexposure prophylaxis, and the suppression of viral load through antiretroviral treatment. In the face of demands for their implementation on population levels, the fear of stimulating risk compensation processes and of increasing riskier sexual practices has retarded their integration into prevention programs. In this article, following a narrative review of the literature on risk compensation using the PubMed database, we offer a critical reflection on the theme using a constructionist approach of social psychology integrated to the theoretical framework of vulnerability and human rights. The use of biomedical technologies for prevention does not consistently induce its users to the increase of riskier practices, and variations on the specificity of each method need to be carefully considered. Alternatives to the theories of sociocognitive studies, such as social constructionist approaches developed in the social sciences and humanities fields, indicate more comprehensive interpretations, valuing the notions of agency and rights. The critical analysis suggests priority actions to be taken in the implementation process: development of comprehensive programs, monitoring and fostering dialog on sexuality, and technical information. We highlight the need to implement a human rights-based approach and to prioritize dialog, stressing how complementary these technologies can be to meet different population needs. We conclude by stressing the need to prioritize sociopolitical changes to restore participation, dialog about sexuality, and emphasis on human rights such as core elements of the Brazilian AIDS policy.

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

BACKGROUND

Limited data are available about the accuracy of postexposure prophylaxis (PEP) prescription in the emergency rooms. Here, we evaluated PEP prescription decision making with respect to the risk of sexual HIV transmission and the exposed person's fear vis-à-vis HIV.

METHODS

Using a risk assessment algorithm, we retrospectively evaluated the adequacy of PEP prescription for all persons presenting at the emergency room of the University Hospital Zurich after consensual sex from 2007 to 2013. We used logistic regression to identify factors that correlate with risk-concordant and risk-discordant decisions.

RESULTS

We documented 975 persons with a total of 1051 visits for PEP: 83% were men, 71% were Swiss, and 37% were men who have sex with men. In 74% of visits, the decisions were concordant with the risk evaluation algorithm (22% discordant, 4% unknown). In 61% (644/1051) PEP was prescribed; however, in 12% (76/644) the prescriptions were without indication of HIV transmission risk and were attributed to the exposed person's request. Importantly, in 10% (101/1051) of all visits, there were potential risks but PEP was not prescribed, either because of physician's decision or exposed person's refusal. The presence of the source partner strongly correlated with appropriately withholding PEP (adjusted odds ratio for giving PEP 0.05; 95% confidence interval: 0.03 to 0.08).

CONCLUSIONS

We found that 22% of PEP decisions were risk discordant because of exposed person's request, incorrect estimation of the sexual transmission risk by the physician, or exposed person's refusal to accept PEP. Emergency physicians may benefit from specialized risk assessment training and patients from education in HIV transmission risk awareness.

Danger in the streets: exposures to bloodborne pathogens after community sharp injuries in Rio de Janeiro, Brazil

OBJECTIVE

Exposures to sharps injuries occurring in the community are relatively frequent. We describe characteristics of community sharp exposures reported in the city of Rio de Janeiro from 1997 to 2010.

METHODS

A cross-sectional analysis of exposure reports to sharps in the community reported to a surveillance system, designed for health care workers, of the Municipal Health Department of Rio de Janeiro. The characteristics of exposed individuals analyzed included types of exposure, the circumstances of the accident, and the prophylaxis offered.

RESULTS

582 exposures were studied. Median age was 30 years and 83 (14%) involved children with less than 10 years of age. Two hundred and seventeen (37%) occurred with sharps found in the streets. The exposure was percutaneous in 515 (89%) and needles where involved in 406 (70%) of them. The sharps were present in the trash in 227 (39%) or in the environment in 167 (29%) of the reports. Professionals who work with frequent contact with domestic or urban waste were 196 (38%). The source was known in 112 (19%) of the exposures and blood was involved in 269 (46%). Only 101 (19%) of the injured subjects reported a complete course of vaccination for hepatitis B. Antiretroviral prophylaxis was prescribed for 392 (68%) of the exposed subjects.

CONCLUSIONS

Sharps injuries occurring in the community are an important health problem. A great proportion would be avoided if practices on how to dispose needles and sharps used outside health units were implemented.

Predictive Factors for HIV Seroconversion Among Individuals Attending a Specialized Center After an HIV Risk Exposure: A Case-Control Study

OBJECTIVE

To better target our current prevention strategies, we assessed factors associated with HIV seroconversion in individuals attending a specialized center after a risk exposure.

MATERIALS AND METHODS

We studied individuals from an HIV Unit's contact risk cohort at a tertiary care hospital in Barcelona, Spain, between 2003 and 2013 and performed a retrospective matched case-control study. Cases were individuals who seroconverted to HIV after at least 3 months since first follow-up visit for a contracting risk. Controls were HIV-negative individuals from the same cohort. Demographics and behavior variables were studied and compared using a McNemar test assessing factors associated with seroconversion. Univariate analysis and binary logistic regression were performed to develop a model for predicting probability of HIV seroconversion. We also evaluated sensitivity and specificity of our model and an area under Receiver Operating Characteristic (ROC) curve was estimated.

RESULTS

Sixty-nine (2.2%) individuals seroconverted after a median (interquartile range) of 24 (9-34) months since last follow-up. Seroconverters were predominantly male (96%) and men who have sex with men (MSM) (94%). No differences were observed regarding risk of exposure. Being MSM [odds ratio (OR) 5.2 (1.4-20.2), p = .01], having a known HIV-positive partner [OR 2.7 (1.2-6.2), p = .02], previous postexposure prophylaxis (PEP) [OR 3.9 (1.0-15.6), p = .05], and having previous sexually transmitted infections (STIs) [OR 4.6 (1.9-10.9), p = .001] were the factors independently associated with HIV seroconversion. The sensitivity and specificity of our model were 64.06% and 73.53%, respectively, and the area under ROC curve was 0.777.

DISCUSSION

HIV seroconversions were observed frequently between individuals attending a specialized center because of a risk exposure. Being MSM, having had previous PEP, an HIV-positive sexual partner, and previous STI were predictive factors for HIV seroconversion. Closer and longer follow-up and/or pre-exposure prophylaxis should be considered to prevent HIV infections in this high-risk population.

Sexual Assault and Sexually Transmitted Infections in Adults, Adolescents, and Children

Survivors of sexual assault are at risk for acquiring sexually transmitted infections (STIs). We conducted literature reviews and invited experts to assist in updating the sexual assault section for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases (STD) treatment guidelines. New recommendations for STI management among adult and adolescent sexual assault survivors include use of nucleic acid amplification tests (NAATs) for detection of Trichomonas vaginalis by vaginal swabs; NAATs for detection of Neisseria gonorrhoeae and Chlamydia trachomatis from pharyngeal and rectal specimens among patients with a history of exposure or suspected extragenital contact after sexual assault; empiric therapy for gonorrhea, chlamydia, and trichomoniasis based on updated treatment regimens; vaccinations for human papillomavirus (HPV) among previously unvaccinated patients aged 9-26 years; and consideration for human immunodeficiency virus (HIV) nonoccupational postexposure prophylaxis using an algorithm to assess the timing and characteristics of the exposure. For child sexual assault (CSA) survivors, recommendations include targeted diagnostic testing with increased use of NAATs when appropriate; routine follow-up visits within 6 months after the last known sexual abuse; and use of HPV vaccination in accordance with national immunization guidelines as a preventive measure in the post-sexual assault care setting. For CSA patients, NAATs are considered to be acceptable for identification of gonococcal and chlamydial infections from urine samples, but are not recommended for extragenital testing due to the potential detection of nongonococcal Neisseria species. Several research questions were identified regarding the prevalence, detection, and management of STI/HIV infections among adult, adolescent, and pediatric sexual assault survivors.

Community-based, nurse-led post-exposure prophylaxis: results and implications

HIV medications can be used as post-exposure prophylaxis to efficaciously prevent an HIV-negative person who has come into contact with HIV from becoming HIV-positive. Traditionally, these medications have been available in emergency departments, which have constituted a barrier for the members of many minority groups who are greatly affected by HIV transmission (i.e. gay, bisexual and other men who have sex with men, and persons who use injection drugs). From 5 September 2013 through 4 September 2015, we sought to increase the use of HIV post-exposure prophylaxis by having registered nurses provide these medications, when indicated, in community clinics in Ottawa, Canada. We undertook a chart review of patients who accessed services for HIV post-exposure prophylaxis in this period. Over the two years of data collection, 112 persons requested HIV post-exposure prophylaxis and 64% (n = 72) initiated these medications. Most (93%, or n = 67, of the 72 initiations) were among men, with 88% (n = 59) of these men reporting same sex sexual partners. Among these 58 men, 31% (n = 18) had sexual contact with other men known to be HIV-positive. Among women (n = 8), five initiated post-exposure prophylaxis: three after needle-sharing contact or sexual contact with a male partner who reportedly shared needles, and two after unprotected vaginal sex with a male partner known to be HIV-positive. Overall, no one was diagnosed with HIV at the four-month HIV testing follow-up, although six persons were diagnosed with HIV from the baseline HIV testing, and an additional four were diagnosed with HIV during routine HIV testing one year after completing post-exposure prophylaxis. In total, nine persons in our sample were thus diagnosed with HIV during the study period, which accounted for 9.4% (n = 10 of 106) of all reported HIV diagnoses in Ottawa during this time. We conclude that nurse-initiated HIV post-exposure prophylaxis can be an effective way to provide HIV prevention services to persons who are at high-risk for HIV.

A randomized clinical trial comparing ritonavir-boosted lopinavir versus maraviroc 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 ritonavir-boosted lopinavir versus maraviroc, both with tenofovir disoproxil/emtricitabine as the backbone.

METHODS

We conducted a prospective, open, randomized clinical trial. Individuals attending the emergency room because of potential sexual exposure to HIV and who met criteria for receiving PEP were randomized to one of two groups: tenofovir disoproxil/emtricitabine (245/200 mg) once daily plus either ritonavir-boosted lopinavir (400/100 mg) or maraviroc (300 mg) twice daily. Five follow-up visits were scheduled for days 1, 10, 28, 90 and 180. 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: NCT01533272.

RESULTS

One-hundred-and-seventeen individuals were randomized to receive ritonavir-boosted lopinavir and 120 to maraviroc (n = 237). PEP non-completion at day 28 was 38% (n = 89), with significant differences between arms [ritonavir-boosted lopinavir 44% (n = 51) versus maraviroc 32% (n = 38), P = 0.05]. We performed a modified ITT analysis including only those patients who attended on day 1 (n = 182). PEP non-completion in this subgroup was also significantly higher in the ritonavir-boosted lopinavir arm (27% versus 13%, P = 0.004). The proportion of patients with low adherence was similar between arms (52% versus 47%, P = 0.56). Adverse events were reported by 111 patients and were significantly more common in the ritonavir-boosted lopinavir arm (72% versus 51%, P = 0.003). No seroconversions were observed during the study.

CONCLUSIONS

PEP non-completion and adverse events were both significantly higher in patients allocated to ritonavir-boosted lopinavir. These data suggest that maraviroc is a well-tolerated antiretroviral that can be used in this setting.

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.

Pre-exposure and postexposure prophylaxes and the combination HIV prevention methods (The Combine! Study): protocol for a pragmatic clinical trial at public healthcare clinics in Brazil

INTRODUCTION

Few results from programmes based on combination prevention methods are available. We propose to analyse the degree of protection provided by postexposure prophylaxis (PEP) for consensual sexual activity at healthcare clinics, its compensatory effects on sexual behaviour; and the effectiveness of combination prevention methods and pre-exposure prophylaxis (PrEP), compared with exclusively using traditional methods.

METHODS AND ANALYSIS

A total of 3200 individuals aged 16 years or older presenting for PEP at 5 sexually transmitted disease (STD)/HIV clinics in 3 regions of Brazil will be allocated to one of two groups: the PEP group-individuals who come to the clinic within 72 h after a sexual exposure and start PEP; and the non-PEP group-individuals who come after 72 h but within 30 days of exposure and do not start PEP. Clinical follow-up will be conducted initially for 6 months and comprise educational interventions based on information and counselling for using prevention methods, including PrEP. In the second study phase, individuals who remain HIV negative will be regrouped according to the reported use of prevention methods and observed for 18 months: only traditional methods; combined methods; and PrEP. Effectiveness will be analysed according to the incidence of HIV, syphilis and hepatitis B and C and protected sexual behaviour. A structured questionnaire will be administered to participants at baseline and every 6 months thereafter. Qualitative methods will be employed to provide a comprehensive understanding of PEP-seeking behaviour, preventive choices and exposure to HIV.

ETHICS AND DISSEMINATION

This study will be conducted in accordance with the resolution of the School of Medicine Research Ethics Commission of Universidade de São Paulo (protocol no. 251/14). The databases will be available for specific studies, after management committee approval. Findings will be presented to researchers, health managers and civil society members by means of newspapers, electronic media and scientific journals and meetings.

Trends in condom use and risk behaviours after sexual exposure to HIV: a seven-year observational study

OBJECTIVE

We aimed to determine the trends in numbers and percentages of sexually exposed persons to HIV (SE) consulting an ED for post-exposure prophylaxis (PEP), as well as predictors of condom use.

STUDY DESIGN

We conducted a prospective-observational study.

METHODS

We included all SE attendances in our Emergency Department (ED) during a seven-year study-period (2006-2012). Trends were analyzed using time-series analysis. Logistic Regression was used to define indicators of condom use.

RESULTS

We enrolled 1851 SE: 45.7% reported intercourse without condom-use and 12.2% with an HIV-infected partner. Significant (p<0.01) rising trends were observed in the overall number of SE visits (+75%), notably among men having sex with men (MSM) (+126%). There were rising trends in the number and percentage of those reporting intercourse without condom-use in the entire population +91% (p<0.001) and +1% (p>0.05), in MSM +228% (p<0.001) and +49% (p<0.001), in Heterosexuals +68% (p<0.001) and +10% (p = 0.08). Among MSM, significant rising trends were found in those reporting high-risk behaviours: anal receptive (+450% and +76%) and anal insertive (+l33% and +70%) intercourses. In a multivariate logistic regression analysis, heterosexuals, vaginal intercourse, visit during the night-shift and short time delay between SE and ED visit, were significantly associated with condom-use.

CONCLUSION

We report an increasing trend in the number of SE, mainly among MSM, and rising trends in high-risk behaviours and unprotected sexual intercourses among MSM. Our results indicate that SE should be considered as a high-risk population for HIV and sexually transmitted diseases.

Non-occupational post-exposure prophylaxis for HIV: 10-year retrospective analysis in Seattle, Washington

Despite treatment guidelines in place since 2005, non-occupational post-exposure HIV prophylaxis (nPEP) remains an underutilized prevention strategy. We conducted a retrospective chart review of patients presenting to a publicly-funded HIV clinic in Seattle, Washington for nPEP between 2000 and 2010 (N = 360). nPEP prescriptions were provided for 324 (90%) patients; 83% of prescription decisions were appropriate according to Centers for Disease Control and Prevention guidelines, but only 31% (N = 111/360) of patients were considered "high risk." In order to use limited resources most efficiently, public health agencies should target messaging for this high-cost intervention to individuals with high-risk HIV exposures.

Overviewing a Nurse-Led, Community-Based HIV PEP Program: Applying the Extant Literature in Frontline Practice

This clinical concept paper overviews a program to facilitate access to postexposure prophylaxis (PEP) for gay, bisexual, and other men who have sex with men. The project, which was a collaborative initiative involving the local School of Nursing, public health unit, AIDS service organization, hospital-based HIV clinic, and an outpatient pharmacy, was implemented to circumvent common barriers to care identified in the literature. In this project, persons who present to one of the two participating clinics after having come, or likely having come, into contact with HIV within the previous 72 hr, are offered rapid HIV testing, also known as point-of-care (POC) testing, to rule out existing HIV infection, and provided with a follow-up appointment booked at the HIV clinic. Clients are also offered comprehensive STI testing, and HIV prevention counseling. The implementation of this collaborative community-based access-to-PEP project demonstrates the application of research to a real-world health care setting, and it is hoped that others will adapt this model to their local setting, enabling ease of access to PEP for members of groups that are disproportionately affected by HIV.

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.

HIV medical providers' perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan areas

INTRODUCTION

In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices.

METHODS

We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression.

RESULTS

More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49).

DISCUSSION

Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.

[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.

Considerations regarding antiretroviral chemoprophylaxis in MSM

PURPOSE OF REVIEW

HIV infection among MSM remains a significant issue. Data relevant to MSM populations from animal models, pharmacokinetic studies and clinical trials are summarized and challenges and potential consequences of use of preexposure prophylaxis (PrEP) by MSM are discussed.

RECENT FINDINGS

Rectal simian-human immunodeficiency virus transmission in macaque models can be prevented by intermittent PrEP dosing. The Preexposure Prophylaxis Initiative (iPrEx) study found that daily oral emtricitabine-tenofovir disoproxyl fumarate (TDF/FTC) decreased HIV infection by 44% among 2499 high-risk MSM. Men with detectable levels of TDF or FTC in plasma and peripheral blood mononuclear cells experienced more than 90% protective effect, emphasizing the importance of adherence. In iPrEX and other studies, PrEP was generally safe and well tolerated. However, it appears that TDF use is associated with a small but significant decrease in mean bone mineral density. No risk compensation has been demonstrated, but this remains an area of potential concern when PrEP is used outside the setting of a placebo-controlled trial. Numerous PrEP trials in MSM are currently underway.

SUMMARY

Oral FTC/TDF is effective in preventing HIV infection among MSM. Optimal PrEP agents and dosing regimens now need to be identified. Understanding the patterns of and impediments to PrEP use among MSM is vital and these should be monitored in ongoing demonstration projects and open-label studies.

Awareness and use of nonoccupational HIV post-exposure prophylaxis among people receiving rapid HIV testing in Spain

OBJECTIVES

This paper examines the awareness and use of nonoccupational HIV post-exposure prophylaxis (nPEP) in Spain, and the factors that influence this awareness.

METHODS

Between June 2009 and July 2010, a mobile unit offered free, rapid HIV tests in a number of Spanish cities. A total of 2545 people were passively recruited and tested, and answered a self-administered questionnaire containing sociodemographic, behavioural and nPEP-related questions. Bivariate and multivariate analyses were performed, stratifying by gender/sexual behaviour.

RESULTS

Some 34% of the responders were men who have sex with men (MSM), 30% were men who have sex exclusively with women (MSW), and 35% were women. Approximately 26% were foreigners, 46% had a university degree, and 51% had previously taken an HIV test. Overall, 22% were aware of nPEP. Only 2% had ever used it; 70% of these after high-risk sexual intercourse. Awareness was higher among MSM (34%) than women (16%) and MSW (15%). Multivariate analysis showed a lack of nPEP awareness to be associated with being born in Latin America, while awareness increased with the number of previous HIV tests among women and MSW. In MSM, awareness was also associated with having a university degree, the degree of interaction with gay culture, number of partners, and use of the internet as the main way of meeting partners.

CONCLUSIONS

nPEP awareness in the studied population was unacceptably low. The promotion of its availability should be made a major objective of prevention programmes, as a complementary measure to condom use.

The Promise of Antiretrovirals for HIV Prevention

With an estimated 2.6 million new HIV infections diagnosed annually, the world needs new prevention strategies to partner with condom use, harm reduction approaches for injection drug users, and male circumcision. Antiretrovirals can reduce the risk of mother-to-child HIV transmission and limit HIV acquisition after occupational exposure. Macaque models and clinical trials demonstrate efficacy of oral or topical antiretrovirals used prior to HIV exposure to prevent HIV transmission, ie pre-exposure prophylaxis (PrEP). Early initiation of effective HIV treatment in serodiscordant couples results in a 96% decrease in HIV transmission. HIV testing to determine serostatus and identify undiagnosed persons is foundational to these approaches. The relative efficacy of different approaches, adherence, cost and long-term safety will affect uptake and impact of these strategies. Ongoing research will help characterize the role for oral and topical formulations and help quantify potential benefits in sub-populations at risk for HIV acquisition.

Non-occupational post-exposure prophylaxis in Victoria, Australia: responding to high rates of re-presentation and low rates of follow-up

In Australia, the non-occupational post-exposure prophylaxis service in Victoria (VNPEPS) maintains a database of non-occupational post-exposure prophylaxis (NPEP) use throughout the state. Through the database the service can monitor and respond to patterns of NPEP presentation, re-presentation and follow-up as well as those who test positive for HIV. We describe a cohort of NPEP individuals from the commencement of the service to 31 December 2009. During this time, 1864 individuals presented for NPEP on 2396 occasions. The majority (85%) were men who have sex with men (MSM) presenting after receptive anal intercourse (56.1%). Repeat NPEP presentations were high (17.5%) and follow-up testing at week 12 post-NPEP was low (34%). Twenty-two patients (1.2%) tested positive for HIV at baseline presentation and six patients seroconverted to HIV during follow-up. The VNPEPS has initiated strategies to encourage behaviour change for those who re-present for NPEP, and to improve rates of week 12 follow-up.

[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.

Nonoccupational post-exposure prophylaxis source tracing: is it really feasible in Australia?

OBJECTIVE

A Swiss nonoccupational post-exposure prophylaxis (NPEP) source-tracing study successfully reduced unnecessary NPEP prescriptions by recruiting and testing source partners of unknown HIV serostatus. The Victorian NPEP Service in Australia attempted to replicate this study with the addition of HIV rapid testing and a mobile service.

METHODS

Patients presenting to two busy NPEP sites who reported a source partner of unknown HIV status were routinely asked if their source could be traced. If the exposed person indicated that their source partner was traceable they were asked to contact them and discuss the possibility of having an HIV test.

RESULTS

No sources were enrolled and the study was terminated.

CONCLUSION

We hypothesize that there are a number of differences between Australia and Switzerland that make source tracing unfeasible in Australia.

The emerging role of antiretroviral agents in HIV prevention

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