Prophylaxis and follow-up after possible exposure to HIV, hepatitis B virus, and hepatitis C virus outside hospital: evaluation of policy 2000-3

Registration of Blood Exposure Accidents in the Netherlands by a Nationally Operating Call Center

Objective.

Healthcare providers and other employees, especially those who do not work in a hospital, may not easily find help after the occurrence of a blood exposure accident. In 2006, a national call center was established in the Netherlands to fill this gap.

Methods.

All occupational blood exposure accidents reported to the 24-hours-per-day, 7-days-per-week call center from 2007, 2008, and 2009 were analyzed retrospectively for incidence rates, risk assessment, handling, and preventive measures taken.

Results.

A total of 2,927 accidents were reported. The highest incidence rates were reported for private clinics and hospitals (68.5 and 54.3 accidents per 1,000 person-years, respectively). Dental practices started reporting incidents frequently after the arrangement of a collective financial agreement with the call center. Employees of ambulance services, midwife practices, and private clinics reported mostly high-risk accidents, whereas penitentiaries frequently reported low-risk accidents. Employees in mental healthcare facilities, private clinics, and midwife practices reported accidents relatively late. The extent of hepatitis B vaccination in mental healthcare facilities, penitentiaries, occupational health services, and cleaning services was low (<70%).

Conclusions.

The national call center successfully organized the national registration and handling of blood exposure accidents. The risk of blood exposure accidents could be estimated on the basis of this information for several occupational branches. Targeted preventive measures for healthcare providers and other employees at risk can next be developed.

Infect Control Hosp Epidemiol 2012;33(10):1017-1023

High HIV incidence among MSM prescribed postexposure prophylaxis, 2000-2009: indications for ongoing sexual risk behaviour

OBJECTIVE

To determine (trends in) HIV incidence among MSM\ who have recently had postexposure prophylaxis (PEP) prescribed in Amsterdam, compared with MSM participating in the Amsterdam Cohort Studies (ACS).

DESIGN AND METHODS

We used data from MSM who were prescribed PEP in Amsterdam between 2000 and 2009, who were HIV-negative at the time of PEP prescription and had follow-up HIV testing 3 and/or 6 months after PEP prescription (n = 395). For comparison, cohort data from MSM participating in the ACS in the same period were used (n = 782). Poisson log-linear regression analyses were performed to model trends in HIV incidence and identify differences in HIV incidence between both cohorts at different time points.

RESULTS

Between 2000 and 2009, among MSM who were prescribed PEP, an overall HIV incidence of 6.4 [95% confidence interval (CI) 3.4-11.2] per 100 person-years was found, compared with an HIV incidence of 1.6 (95% CI 1.3-2.1) per 100 person-years among MSM participating in the ACS (P < 0.01). In both cohorts, an increasing trend in HIV incidence over time was observed [incidence rate ratio (IRR(per calendar year)) 1.3 (95% CI 0.9-1.7) and 1.1 (95% CI 1.0-1.2) among MSM prescribed PEP and MSM of the ACS, respectively]. The difference in HIV incidence between both cohorts was most evident in more recent years [IRR(PEP versus ACS in 2009) 4.8 (95% CI 2.0-11.5)].

CONCLUSION

Particularly in more recent years, MSM recently prescribed PEP had a higher HIV incidence compared with MSM participating in the ACS, indicating ongoing sexual risk behaviour.

Physicians' and patients' adherence to antiretroviral prophylaxis after sexual exposure to HIV: results from South-Eastern France

French national guidelines for the management of HIV non-occupational post-exposure (nPEP) were issued in 1998 and updated in 2003. NPEP is available and free of charge in all emergency or AIDS care units of French hospitals. A regional survey was carried out to study physicians' adherence to national guidelines, and determinants of adherence to nPEP follow-up in individuals sexually exposed to HIV. The survey was based on retrospective data collection of all consultations for nPEP made in the three AIDS information centers in South-Eastern France (January 2001-December 2002). Information included personal data, type of exposure, and treatment at the first visit after exposure and during follow-up. Exposures were classified into high risk (treatment highly recommended), moderate risk (treatment possibly recommended) and negligible risk (treatment never recommended) categories, according to the level of HIV risk of sexual transmission as indicated by the French national nPEP guidelines. Among the 910 sexual exposures, 56%, 37%, and 4% were classified as cases with high, moderate, and no risk respectively. NPEP was prescribed to 85% of cases. HIV risk of sexual exposure was significantly associated with nPEP receipt though more than half of the cases with negligible risk received nPEP. Independent characteristics associated with non-adherence to nPEP follow-up were younger age, being referred to hospital by a physician, sexual exposure with a casual partner or sexual assault, and "moderate risk" exposure. Better information should be provided to physicians prescribing nPEP to limit over-prescription while new strategies should be implemented to improve follow-up of individuals receiving nPEP, especially those who are younger or survivors of sexual assault.

Hepatitis infection in the treatment of opioid dependence and abuse

Many new and existing cases of viral hepatitis infections are related to injection drug use. Transmission of these infections can result directly from the use of injection equipment that is contaminated with blood containing the hepatitis B or C virus or through sexual contact with an infected individual. In the latter case, drug use can indirectly contribute to hepatitis transmission through the dis-inhibited at-risk behavior, that is, unprotected sex with an infected partner. Individuals who inject drugs are at-risk for infection from different hepatitis viruses, hepatitis A, B, or C. Those with chronic hepatitis B virus infection also face additional risk should they become co-infected with hepatitis D virus. Protection from the transmission of hepatitis viruses A and B is best achieved by vaccination. For those with a history of or who currently inject drugs, the medical management of viral hepatitis infection comprising screening, testing, counseling and providing care and treatment is evolving. Components of the medical management of hepatitis infection, for persons considering, initiating, or receiving pharmacologic therapy for opioid addiction include: testing for hepatitis B and C infections; education and counseling regarding at-risk behavior and hepatitis transmission, acute and chronic hepatitis infection, liver disease and its care and treatment; vaccination against hepatitis A and B infection; and integrative primary care as part of the comprehensive treatment approach for recovery from opioid abuse and dependence. In addition, participation in a peer support group as part of integrated medical care enhances treatment outcomes. Liver disease is highly prevalent in patient populations seeking recovery from opioid addiction or who are currently receiving pharmacotherapy for opioid addiction. Pharmacotherapy for opioid addiction is not a contraindication to evaluation, care, or treatment of liver disease due to hepatitis virus infection. Successful pharmacotherapy for opioid addiction stabilizes patients and improves patient compliance to care and treatment regimens as well as promotes good patient outcomes. Implementation and integration of effective hepatitis prevention programs, care programs, and treatment regimens in concert with the pharmacological therapy of opioid addiction can reduce the public health burdens of hepatitis and injection drug use.

Variation in interpretation and counselling of blood exposure incidents by different medical practitioners

BACKGROUND

Blood exposure incidents pose a risk for transmission of bloodborne pathogens for both health care workers and public health. Despite several national and international guidelines, counsellors have often different opinions about the risks caused by these incidents. Little is known about the consequences of these variations in risk assessment on the effectiveness of the treatment and the costs for the health care system.

METHODS

The aim of this study was to reveal differences among diverse groups of counsellors in assessing the same blood exposure incidents. Subjects included 4 different kinds of counsellors: public health physicians from infectious disease departments and medical microbiologists, occupational health practitioners, and HIV/AIDS specialists from hospital settings. Surveys with cases of blood exposure incidents were sent to the counsellors in The Netherlands asking questions about their risk assessment and consequent treatment. Questions were categorized for hepatitis B virus (HBV), hepatitis C virus (HCV), and HIV risks.

RESULTS

Of the 449 surveys sent, 178 were returned, of which 158 were eligible for the study. In general, occupational health practitioners and medical microbiologists showed a more rigorous approach especially with regard to prophylactic treatment when counselling HBV risk situations, whereas public health physicians and HIV/AIDS specialists were more thorough in the handling of HCV risk accidents. In HIV counselling, HIV/AIDS specialists were far more rigorous in their treatment than the other groups. For 7 of the total of 12 cases, the risk assessment with regard to HBV, HCV, and HIV differed significantly.

CONCLUSION

The assessment of blood exposures significantly differs depending on the medical background of the counsellor handling the incident, leading to remarkable inconsistencies in the response to prevent the transmission of bloodborne pathogens and/or to increased costs for unnecessary diagnostic tests and preventive measures. Although national guidelines for the counselling and treatment of blood exposure incidents are essential, the assessment of blood exposure incidents should be limited to as few as possible, well-trained professionals, operating in regional or national call centers, to ensure comparable assessment and corresponding application of preventive measures for all victims.

Trends in HIV Postexposure Prophylaxis Prescription and Compliance After Sexual Exposure in Amsterdam, 2000–2004

OBJECTIVE

The objective of this study was to evaluate trends in HIV postexposure prophylaxis (PEP) requests after sexual exposure, compliance, and outcome of follow-up HIV tests.

STUDY DESIGN

The authors conducted a retrospective analysis of all HIV PEP requests after sexual exposure between January 1, 2000, and December 31, 2004, in Amsterdam.

RESULTS

In 5 years, there was a very modest increase in PEP requests, of which most (75%) came from men who have sex with men (MSM). Although 70% reported side effects, 85% completed their PEP course. Sexual assault victims less often completed their course (odds ratio [OR] = 0.1; 95% confidence interval [CI] = 0.05-0.4, P = 0.001). People who used HIV PEP more often complied with follow-up tests than people who did not use PEP (OR = 3.5; 95% CI = 1.6-7.9, P = 0.002). One HIV seroconversion was found caused by a later exposure than that for which PEP was given.

CONCLUSIONS

Despite a widely available PEP program in Amsterdam, the number of PEP requests remained low. Most people completed their PEP course; compliance with follow-up HIV testing was high.

Postexposure prophylaxis after sexual exposure to HIV

PURPOSE OF REVIEW

HIV postexposure prophylaxis is often recommended following potential sexual exposure to HIV. Recent data address the effectiveness of postexposure prophylaxis and prevention counseling, cost-effectiveness, antiretroviral options, challenges with nonoccupational postexposure prophylaxis among adolescents and children and following sexual assault in high HIV prevalence areas, and a successful program in Amsterdam.

RECENT FINDINGS

Postexposure prophylaxis is not completely protective. Seroconversion may result from antiretroviral failure or from ongoing exposures. Postexposure prophylaxis associated risk reduction counseling results in reductions in subsequent risk behavior. Programs that target outreach and limit prescriptions to those with exposure sources who are at risk of being HIV infected are cost-effective. Less restrictive guidelines result in more prescriptions for low-risk exposures; this practice is not cost-effective. The ideal antiretrovirals for postexposure prophylaxis use have not been established. Tenofovir has several attractive properties. Developing systems to support the effective delivery of postexposure prophylaxis among children and adolescents and following sexual assault in high HIV prevalence, resource limited settings is challenging.

SUMMARY

Numerous national and international guidelines recommend postexposure prophylaxis following potential sexual exposure to HIV. Maximizing adherence and minimizing subsequent HIV exposures will be critical to enhancing the effectiveness of this HIV prevention intervention.

Determinants of adherence to non-occupational post HIV exposure prophylaxis

We conducted a study on 140 patients who sought advice at hospital after a non-occupational exposure. The full 28-day course of prophylactic antiretroviral therapy was completed by 109 patients. No HIV contamination was observed. Factors associated with suboptimal adherence were African ethnicity [odds ratio (OR) 13.3, 2.02-87.54] and oral sexual intercourse (OR 8.35, 1.66-41.99). Compliance with prophylactic antiretroviral therapy can be increased by addressing social and psychological barriers to adherence.