Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus

Medical approach to children who may have been sexually abused-a narrative review

The medical approach to children who may have been sexually abused involves several issues and aspects that need to be considered. The medical examination of children with suspected sexual abuse is important, but a detailed medical history from the child and the parents or caretakers is always part of every thorough examination. It can take a long time until victims disclose their abuse and physical signs of abuse may no longer be visible at the time of examination. If the physical examination is performed non-acutely, only 2.2% of sexually abused girls show diagnostic signs of injury. An experienced examiner should ideally perform the examination in suspected sexual abuse of children. Knowledge of the current literature is of importance, as the interpretation of findings has changed over the past decades and it can be difficult to differentiate between normal variants, symptoms of other medical problems, and signs of sexual assault. Furthermore, sexual abuse of children presents in various form, not necessarily leading to physical injuries. Since 1992, Adams et al. publish a regularly updated system for the classification of anogenital findings in children with suspected sexual abuse, including a detailed list of physical findings and infections related to sexual abuse. The purpose of this article is to summarize important aspects of the medical approach to children with suspected sexual abuse according to the current literature.

Infection control in child daycare centers: logistics, knowledge, and practices of caregivers

Background

Children attending daycare centers (DCCs) are at high risk of contracting infectious diseases due to several factors including lack of knowledge among the caregivers about infection prevention and control practices. The objectives were to describe the DCC features, infrastructure, and infection control logistics, to assess knowledge of DCC caregivers regarding infectious diseases, and to assess their infection control practices.

Methods

Using a cross-sectional design, 402 caregivers working in 59 DCCs in three districts in Alexandria, Egypt were included. Data were collected using a data collection sheet about the DCC features, a structured interviewing questionnaire to collect data on caregivers’ personal characteristics, knowledge about infectious diseases, and the best infection control practices and an observational infection control practices checklist. Multiple analysis of variance was used to test the difference in two or more vectors of means (mean knowledge scores about infectious diseases and about infection control). Post hoc test using Tukey Honest Significant Difference was used to determine which groups in the sample differ. Regression analysis models were used to identify factors affecting knowledge score of caregivers, and to estimate the magnitude of the association between different variables and the level of practice of caregivers (poor/fair and good).

Results

Satisfactory features of the DCCs included the aeration, level of cleanliness, and availability of hand washing facilities, while the availability of gloves and aprons, alcohol-based products, and medical examination rooms were not satisfactory. Only 2.5% of caregivers had a good level of knowledge. Level of education was the only factor statistically associated with the level of knowledge. About 31% and 17% had poor and good practice score percent, respectively. District and daily working hours were the only variables statistically associated with the level of practice.

Conclusion

The level of knowledge and practice of caregivers was below optimum.

Addressing the dual health epidemics of HIV and sexual abuse among children and adolescents in Kenya: uptake of HIV counseling and post-exposure prophylaxis

Purpose

Child sexual abuse and HIV are key health challenges in Kenya. In 2015, LVCT Health conducted a study aimed at assessing the quality of HIV-related services offered to child survivors of sexual violence in public health facilities.

Materials and methods

A qualitative data collection approach was utilized. Qualitative data were collected through in-depth interviews with 31 providers. Quantitative methods included a retrospective review of 164 records of child survivors of rape who had accessed services 6 months prior to the commencement of the study. SPSS Version 22 was used in the descriptive analysis of the medical records. Client exit interviews and observation data were analyzed using MS Excel. In-depth interviews were analyzed using a thematic analytical approach.

Results

Twenty-seven percent (n=164) survivors were documented to have received the first dose of postexposure prophylaxis (PEP). Providers did not conduct HIV pre- and posttest counseling for the survivors. There were no longitudinal follow-up mechanisms to ensure child survivors initiated on PEP adhered to the treatment plan. Less than 30% of survivors returned to the facility for PEP adherence counseling and follow-up HIV testing. Twenty providers cited capacity gaps in undertaking HIV risk assessment for child survivors. Limited availability of PEP is a barrier to HIV prevention, as most departments only offer services between 8 am and 5 pm. HIV tests were only available on weekdays before 5 pm. PEP being out of stock remains a barrier to HIV prevention.

Conclusion

Existing post-rape care services are not adequately structured to facilitate delivery of quality HIV-related services to child survivors. Health provider capacity in the management of children remains weak due to lack of skill-based training on the dynamics of responding to the needs of child survivors. There is a need for standard operating procedures and training modules on the prevention of HIV in the context of child sexual abuse.

Improving HIV post-exposure prophylaxis rates after pediatric acute sexual assault

The purpose of our study was to increase the rate of children with appropriate HIV-PEP regimens among those diagnosed with sexual assault in The Children's Hospital of Philadelphia Emergency Department (ED). The outcome measure was the percent of patients receiving correct HIV-PEP. We retrospectively reviewed 97 charts over 31 months to define the baseline rate of children receiving appropriate HIV-PEP regimens (pre QI-implementation period: 2/2012-8/2014). Among children in which HIV-PEP was indicated following sexual assault, 40% received the recommended 28-day course. Root cause analysis indicated prescribing errors accounted for 87% of patients not receiving appropriate HIV-PEP. Process drivers included standardizing care coordination follow-up calls to elicit specific information about HIV-PEP, ED educational initiatives targeted at HIV-PEP prescribing, revision of the clinical pathway to specify indicated duration of HIV-PEP, and revision of the order set to auto-populate the number of days for the HIV-PEP prescription. During the QI-implementation period (9/2014-4/2015), the rate of appropriate HIV-PEP increased to 64% (median 60%) and the average number of days between incorrect HIV-PEP regimens was 24.5. Post QI-implementation (5/2015-3/2016), the rate of appropriate HIV-PEP increased to 84% (median 100%) and the average number of days between incorrect HIV-PEP regimens increased to 78.4. A multifaceted quality improvement process improved the rate of receipt of appropriate HIV-PEP regimens for pediatric victims of sexual assault. Decision support tools are instrumental in sustaining ideal care delivery, but require ongoing evaluation and improvement in order to remain optimally effective.

Sexually Transmitted Infections and Children: What the PNP Should Know

Sexual abuse is a problem of epidemic proportions in the United States. In their practice, pediatric nurse practitioners will likely encounter children who have experienced sexual abuse-both those who have and have not previously been identified as victims. Sexually transmitted infections (STIs) are rare in sexually abused children and adolescents. However, when present, they can be crucial to making the diagnosis of sexual abuse and protecting children. This continuing education article will assist the pediatric nurse practitioner in interpreting the relationship between STIs and sexual abuse, correctly testing for STIs, and treating STIs in children and adolescents.

Care of the Adolescent After an Acute Sexual Assault

Sexual violence is a broad term that encompasses a wide range of sexual victimizations. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2008, additional information and data have emerged about sexual violence affecting adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on the acute assessment and care of adolescent victims who have experienced a recent sexual assault. Follow-up of the acute assault, as well as prevention of sexual assault, are also discussed.

Post-exposure prophylaxis guidelines for children and adolescents potentially exposed to HIV

UK guidelines for HIV post-exposure prophylaxis (PEP) in adults have recently been updated. Indications for PEP have been modified and there has been a change in the recommended antiretroviral therapy for adults to a combination of raltegravir with tenofovir and emtricitabine (Truvada). Raltegravir and tenofovir are now available in paediatric formulations and offer improved safety and tolerability over previously recommended ritonavir-boosted lopinavir with zidovudine. This guideline provides recommendations for those caring for children potentially exposed to HIV and other bloodborne viruses in primary care, emergency departments, secondary care and specialist paediatric HIV centres.

Uptake and repeat use of postexposure prophylaxis in a community-based clinic in Los Angeles, California

Postexposure prophylaxis (PEP) has become an important tool for HIV prevention in the men who have sex with men (MSM) communities within Los Angeles County. However, it is unclear as to whether the most sexually at-risk MSM populations are accessing PEP services. Furthermore, it is unclear what behavioral risk factors differentiate individuals who utilize PEP once (single PEP) versus those who utilize it multiple times (re-PEP). Data were collected between May 2011 and December 2012 on all clients enrolled in the Los Angeles LGBT Center's (the Center) PEP-LA program as well as on all sexually transmitted infection (STI) screening clients visiting the Center. Multivariate logistic regression models were used to analyze results. PEP clients had greater odds of having a history of gonorrhea in the past year when compared to high-risk, non-PEP clients (OR: 1.71; CI: 1.25-2.35). Furthermore, they had greater odds of using methamphetamines (OR: 1.71; CI: 1.30-2.24) and inhaled nitrates (OR: 1.62; CI: 1.30-2.01) in the past 12 months when compared to high-risk, non-PEP clients. Re-PEP clients had greater odds of methamphetamine use than single PEP clients (OR: 2.80; CI: 1.65-4.75). There were no significant differences by race/ethnicity between high-risk, non-PEP clients and PEP clients in either the entire cohort or MSM only sample. However, African Americans made up 8.5% of persons accessing PEP services but 16.7% of persons who tested HIV positive. Similar proportions of PEP use by race/ethnicity are problematic considering the disproportionate burden of HIV infections in the African American community. Although uptake among the highest risk populations has been brisk (n=649), inequities based upon race/ethnicity suggest the need for increased outreach.

Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

Uptake to HIV post-exposure prophylaxis in Haiti: opportunities to align sexual violence, HIV PEP and mental health

Sexual violence is a public health problem in Haiti, potentially augmenting HIV transmission. Reports from L'Hôpital de l'Université d'État d'Haiti (HUEH) suggest severe underutilization of antiretroviral post-exposure prophylaxis (ARV-PEP) among rape survivors. Cross-sectional design using mixed methods. Informational interviews were conducted with HUEH personnel to learn about post-rape service offerings. HUEH surveillance data were used to estimate the sexual assault reporting rate/100,000 and to examine the proportion of survivors receiving ARV-PEP within 72 hr, stratified by age (<18 years, ≥18 years). Informational interviews revealed that survivors were navigated through two hospital algorithms to receive post-rape care; however, <5% of victims sought mental health services. Surveillance data show that 2193 sexual assault survivors (adult and pediatric) reported a rape to HUEH personnel between 2004 through first quarter of 2010. Annual estimates suggest a twofold increase comparing cases in 2004 versus 2009. Between 2008 and 2009, uptake to ARV-PEP within 72 hr was lower for pediatric (38.4%; N = 131/341) compared with adult survivors (60.1%; N = 83/138) (χ(2)  = 18.8, P < 0.001). The prioritization of funding and comprehensive interventions that align sexual violence, HIV, and mental health is crucial to support the timely uptake to ARV-PEP.

Sexual abuse

Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.

Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries

OBJECTIVES

To describe characteristics and management of people with community acquired needle stick injuries (CANSI) attending urban emergency departments; and suggest a guideline to improve assessment, management, and documentation.

METHODS

A retrospective analysis of cases with CANSI attending emergency departments in two tertiary hospitals between 2001 and 2005 using medical record review with follow up phone and written survey.

RESULTS

Thirty-nine cases met the criteria for CANSI. Persons younger than 30 years sustained 48.72% of all injuries. Source serology was available for only five cases (12.82%). Thirty-one of thirty-nine patients (79.49%) were classed as not immune to hepatitis B but only four of these (12.90%) received both hepatitis B vaccination and hepatitis B immunoglobulin. Six patients (15.38%) received HIV prophylaxis; of which two (33.33%) did not receive baseline HIV testing. Of ten patients referred to immunology clinic for follow up only two (20.00%) attended at 6 months.

CONCLUSION

We have identified groups that are at high risk of CANSI, including young males, security workers and cleaners. In the majority of cases protection against hepatitis B was inadequately provided, and a substantial proportion had inadequate baseline assessment and documentation. A guideline is suggested that may be used to improve these deficits.

Postnatal infant HIV prophylaxis: a survey of U.S. practice

For neonates identified as at increased risk of acquiring HIV perinatally, the optimal postnatal prophylaxis regimen is not known. Current United States Public Health Service guidelines recognize that combination postnatal prophylaxis may be considered in some situations but that there are little data regarding the effectiveness and safety of any postnatal regimen besides zidovudine. The actual use of combination postnatal regimens in the United States has not previously been described. We conducted a national, Web-based survey between December 2009 and January 2010 to describe the percent of providers who prescribe combination postnatal prophylaxis, the antiretroviral combinations they used, and the risk factors that might elicit combination postnatal prophylaxis. 472 known or possible perinatal HIV providers were queried; 42% (n = 197) responded and 68% of respondents (134) were eligible to complete the survey. Sixty-two percent (n = 83) of participating providers reported use or recommendation of combination postnatal prophylaxis in the last year. Three drugs, zidovudine, lamivudine and nevirapine, comprised 77% of first-choice combination regimens. Lopinivir-ritonivir (LPV/RTV) was included in 16% of all reported regimens. Combination postnatal prophylaxis was strongly preferred in patient-based scenarios with additional risk factors for perinatal HIV transmission.

Thinking about HIV infection

Mother-to-child transmission of HIV can occur during pregnancy, labor, delivery, and breastfeeding. Evidence-based interventions (routine screening of pregnant women, initiation of antiretroviral drugs for mother's treatment or prevention of MTCT, and avoiding breastfeeding) have reduced transmission rates in the United States from 25% to 30% to less than 2%. Triple-drug combination antiretroviral therapy effectively controls HIV infection and improves survival and quality of life for HIV-infected children and adolescents. Initial regimens use combinations of two NRTIs together with an NNRTI or a ritonavir-boosted PI. These regimens have been shown to increase CD4 counts and achieve virologic suppression. Prevention of serious and opportunistic infections reduces morbidity and mortality in children and adolescents who have HIV infection. Recommendations for immunizations and chemoprophylaxis vary with the patient's CD4 count. Condoms made from latex, polyurethane, or other synthetic materials have been shown to decrease the transmission of STIs, including HIV infection.

Presentation of child sexual abuse cases to Queen Elizabeth Central Hospital following the establishment of an HIV post-exposure prophylaxis programme

AIM

To review the presentation and management of child sexual abuse cases presenting to Queen Elizabeth Central Hospital (QECH), Blantyre, since the introduction of an HIV postexposure prophylaxis programme.

METHODS

Demographic and medical data was collected from all children presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi between January 2005 and February 2007 with alleged child sexual abuse (CSA).

RESULTS

Between January 2005 and February 2007, 217 children presented with alleged CSA. This an average of 3 more per month since the previous year, a 57 percent increase. Physical examination showed signs of trauma 60% (130/217) of cases. 63% (137/217) of the cases presented within 72 hours of defilement. Overall in 42% (92/217) of children a one month course of HIV PEP was indicated and given. In 58% (125/217) HIV PEP was not indicated in view of normal examination, presentation too late (>72 hrs after abuse), multiple abuse episodes in the last 6 months, HIV test positive or HIV test refused. In 66% (144/217) of assessed children antibiotic treatment was given for the prevention and/ or treatment of sexually transmitted infections (STIs).

CONCLUSIONS

The introduction of an HIV PEP programme for victims of CSA has lead to increased numbers presenting and being treated. In conclusion it is likely that a significant number of children have been prevented from acquiring HIV and other STIs following CSA. The key area where our service needs to be improved is in establishing documented follow up of all cases to monitor medication compliance, side effects and rates of HIV seroconversion following CSA.

Adolescents and HIV: prevention and clinical care

The incidence of HIV infection has increased to alarming proportions among minority youth, in particular among young men who have sex with men and among teenage girls. The unique socioeconomic, behavioral, and emotional vulnerability of adolescents for sexually transmitted diseases, including HIV, requires early identification of HIV infection for linkage to care. Differences in the clinical and psychosocial presentations of youth with perinatally versus behavioral acquired HIV infection are important and influence the acceptance of illness, self-efficacy, and antiretroviral treatment adherence. The ideal multidisciplinary team approach of culturally sensitive services for youth integrates clinical care, psychosocial and peer support interventions, transition planning, primary and secondary prevention, as well as comprehensive reproductive adolescent health services.

HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault

BACKGROUND

The appropriate use of antiretroviral medications to protect against infection with human immunodeficiency virus (HIV) is unclear in cases of sexual assault of children, for whom the perpetrator's risk of HIV is often unknown, and physical proof of sexual contact is usually absent.

OBJECTIVE

In an effort to clarify prescribing practices for HIV post-exposure prophylaxis (PEP) at our institution, we examined records of all children tested for HIV for prevalence of infection, our experience with prescribing PEP, and follow-up rates.

DESIGN/METHODS

Medical records at a sexual abuse clinic of all children tested for HIV during a 38-month period were reviewed for information concerning risk factors for HIV acquisition, STI test results, and PEP experience. Children were defined as PEP-eligible if they were within 96 hours of assault, and there was a report of sexual contact with the potential to transmit HIV.

RESULTS

One thousand seven hundred and fifty children were tested for HIV during the study period. Five children had a positive HIV ELISA, but only one child was confirmed HIV-positive. Three hundred and three children were eligible to receive HIV-PEP, but it was only offered to 16 (5.3%), of whom 15 accepted the medications. None of the children prescribed PEP completed follow-up, but 11 children had limited follow-up.

CONCLUSIONS

Our results indicate that the prevalence of HIV infection among sexually abused children in our population is low, and follow-up rates are poor. Intensive efforts to try to ensure follow-up are warranted whenever PEP is prescribed. Further research may help better define the efficacy of PEP in sexually abused children and adolescents.

Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion

OBJECTIVES

Although anxiety exists concerning the perceived risk of transmission of bloodborne viruses after community-acquired needlestick injuries, seroconversion seems to be rare. The objectives of this study were to describe the epidemiology of pediatric community-acquired needlestick injuries and to estimate the risk of seroconversion for HIV, hepatitis B virus, and hepatitis C virus in these events.

METHODS

The study population included all of the children presenting with community-acquired needlestick injuries to the Montreal Children's Hospital between 1988 and 2006 and to Hôpital Sainte-Justine between 1995 and 2006. Data were collected prospectively at Hôpital Sainte-Justine from 2001 to 2006. All of the other data were reviewed retrospectively by using a standardized case report form.

RESULTS

A total of 274 patients were identified over a period of 19 years. Mean age was 7.9 +/- 3.4 years. A total of 176 (64.2%) were boys. Most injuries occurred in streets (29.2%) or parks (24.1%), and 64.6% of children purposely picked up the needle. Only 36 patients (13.1%) noted blood on the device. Among the 230 patients not known to be immune for hepatitis B virus, 189 (82.2%) received hepatitis B immunoglobulin, and 213 (92.6%) received hepatitis B virus vaccine. Prophylactic antiretroviral therapy was offered beginning in 1997. Of the 210 patients who presented thereafter, 82 (39.0%) received chemoprophylaxis, of whom 69 (84.1%) completed a 4-week course of therapy. The use of a protease inhibitor was not associated with a significantly higher risk of adverse effects or early discontinuation of therapy. At 6 months, 189 were tested for HIV, 167 for hepatitis B virus, and 159 for hepatitis C virus. There were no seroconversions.

CONCLUSIONS

We observed no seroconversions in 274 pediatric community-acquired needlestick injuries, thereby confirming that the risk of transmission of bloodborne viruses in these events is very low.

Care of the adolescent sexual assault victim

Sexual assault is a broad-based term that encompasses a wide range of sexual victimizations including rape. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2001, additional information and data have emerged about sexual assault and rape in adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on assessment and care of sexual assault victims in the adolescent population.

Compliance in Rhode Island emergency departments with American Academy of Pediatrics recommendations for adolescent sexual assaults

OBJECTIVES

We assessed the offering of American Academy of Pediatrics-recommended tests and prophylaxes after sexual assault to adolescents who presented to Rhode Island emergency departments for 3 categories of sexual exposures: sexual assault, consensual sex, and suspected sexual abuse.

PATIENTS AND METHODS

This study entailed a retrospective review of visits for adolescent sexual exposures across 11 Rhode Island emergency departments between January 1995 and June 2001. Cases were identified through billing codes. Offering of each test and prophylaxis was compared by gender, category of sexual exposure, and type of sexual assault. Multivariable linear regression models were used to identify factors associated with the offering of a greater number of tests and prophylaxes after sexual assault.

RESULTS

The vast majority of emergency department visits for adolescent sexual exposures were by sexually assaulted girls (82.5%). Across the 3 sexual exposure categories, girls were offered tests and prophylaxes more often than boys (eg, chlamydia or gonorrhea testing and prophylaxis). Among sexually assaulted adolescents, 32.8% of girls and no boys were offered all recommended tests and prophylaxes. The multivariable linear regression found that vaginally and/or anally assaulted girls were offered, on average, 2.5 more tests and prophylaxes than patients with other types of sexual assaults. Girls presenting for care at the state's women's health care specialty hospital emergency departments were offered 1.7 more tests and prophylaxes than those evaluated in general hospital emergency departments.

CONCLUSIONS

Many adolescents did not receive American Academy of Pediatrics-recommended tests and prophylaxes after sexual assault. Boys received fewer tests than girls. Testing and prophylaxis varied by type of emergency department. Efforts are needed to improve and standardize emergency department medical management of adolescent sexual exposures.

Multiple needle-stick injuries with risk of human immunodeficiency virus exposure in a primary school

Twenty children received needle-stick injuries with a risk of exposure to human immunodeficiency virus type 1 during an incident in a primary school playground. All were counseled and offered human immunodeficiency virus postexposure prophylaxis. All 20 children started postexposure prophylaxis, and 19 attended for follow-up testing 3 months later. More than one-half of the children completed the full 4-week course of treatment. None of the 19 children tested seroconverted after the incident.

Use of antiretroviral HIV post-exposure prophylaxis in sexually abused children and adolescents treated in an inner-city pediatric emergency department

BACKGROUND

In 2002, Georgia had the United States' eighth highest number of persons living with AIDS. Human immunodeficiency virus (HIV) transmission as a result of sexual abuse is uncommon but definitely occurs. In certain circumstances of sexual abuse, antiretroviral post-exposure prophylaxis (ARV-PEP) has been suggested as a means to decrease the risk of HIV infection. Our objective was to assess the utilization of ARV-PEP in patients being evaluated for sexual abuse at a pediatric emergency department in a city with high HIV prevalence.

METHODS

A retrospective survey of the characteristics of sexual abuse victims was conducted using information abstracted from sexual abuse report forms of minors examined in 2002 at an inner-city Atlanta children's hospital.

RESULTS

Of 227 victims, aged 9 months to 18 years, most were Black, inner-city residents; 190 (84%) patients were female. Only 87 of 227 (38.3%) were seen within 72 h of the abuse, the time frame for offering ARV-PEP. Twenty-three of the 87 had anogenital trauma or bleeding. Five (5.7%), were provided ARV-PEP, whereas 60 (69%) received antibiotic prophylaxis for non-HIV diseases. Those assaulted by strangers were greater than 10 times more likely to be provided ARV-PEP than others (p=.02). Assailants of the 82 victims who did not receive ARV-PEP included 22 strangers and 60 "acquaintances" of unknown serostatus.

CONCLUSIONS

For a high HIV prevalence area, the proportion of sexual abuse victims prescribed ARV-PEP was small in relation to those at risk of HIV sexual exposure. Clinicians should be provided guidance on interpretation of community HIV and sexual abuse victim data to assess the appropriateness of ARV-PEP.

Reducing the risk of HIV infection associated with illicit drug use

Substance abuse, specifically the use of illicit drugs that are administered intravenously, continues to play a role in the transmission of human immunodeficiency virus type 1 (HIV-1) among adolescents and young adults (youth). Risks of HIV-1 infection may result from direct exposure to contaminated blood through sharing of injection drug equipment and from unsafe sexual practices (while under the influence of drugs and/or in exchange for drugs). Reducing the risk of HIV-1 infection that is associated with illicit drug use requires prevention education and prompt engagement in treatment. Providing patients with education, instruction on decontamination of used injection drug equipment, improved access to sterile syringes and needles, and postexposure prophylaxis may decrease their risk of acquiring HIV-1 infection. Pediatricians should assess risk behaviors as part of every health care encounter, including queries about tobacco, alcohol, and marijuana use. The risks and benefits of postexposure prophylaxis with antiretroviral drugs should be considered for youth with a single recent (within 72 hours) high-risk exposure to HIV-1 through sharing needles/syringes with an HIV-1-infected individual or having unprotected intercourse with an individual who engages in injection drug use. Such prophylaxis must be accompanied by risk-reduction counseling, appropriate referrals for treatment, and evaluation for pregnancy and associated sexually transmitted infections. There is an urgent need for more substance-abuse prevention and treatment programs, legislation that facilitates unencumbered access to sterile syringes, and expedient availability of reproductive health care services for sexually active youth, including voluntary HIV-1 counseling and testing.

Introduction of HIV post-exposure prophylaxis for sexually abused children in Malawi

AIMS

To improve the care of children who are victims of child sexual abuse (CSA) by routinely assessing eligibility for HIV post-exposure prophylaxis (PEP) and to investigate the feasibility, safety, and efficacy of such treatment started in a paediatric emergency department in Malawi.

METHODS

Children presenting to the Queen Elizabeth Central Hospital, Blantyre between 1 January 2004 and 31 December 2004 with a history of alleged CSA were assessed for eligibility for HIV PEP and followed prospectively for six months.

RESULTS

A total of 64 children presented with a history of alleged CSA in the 12 month period; 17 were offered PEP. The remainder were not offered PEP because of absence of physical signs of abuse (n = 20), delay in presentation beyond 72 hours from assault (n = 11), repeated sexual abuse in the preceding six months (n = 15), and HIV infection found on initial testing (n = 1). No family refused an HIV test. No side effects due to antiretroviral therapy were reported. Of the 17 children commenced on PEP, 11 returned for review after one month, seven returned at three months, and two of 15 returned at six months post-assault. None have seroconverted.

CONCLUSIONS

In a resource-poor setting with a high HIV prevalence, HIV PEP following CSA is acceptable, safe, and feasible. HIV PEP should be incorporated in to national guidelines in countries with a high community prevalence of HIV infection.

Human bites and blood exposures in New York City schools

The epidemiology of human bites and blood exposures in urban schools has not been described. The authors reviewed 734 human bite and blood exposure incidents in New York City schools from September 1999 to June 2001. School site, age, gender, body site, temporal distributions, and underlying health status of individuals were reviewed. Nine incidents involved children known or suspected to be HIV-infected. Medical interventions included EMS involvement, emergency room treatment, hospitalization, vaccine administration, laceration suturing, systemic antibiotic therapy, and serologic evaluation for transmission of blood-borne pathogens. These incidents occur with a high prevalence in NYC schools and have potential for serious outcomes.

The evaluation of sexual abuse in children

This clinical report serves to update the statement titled "Guidelines for the Evaluation of Sexual Abuse of Children," which was first published in 1991 and revised in 1999. The medical assessment of suspected sexual abuse is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data. The role of the physician may include determining the need to report sexual abuse; assessment of the physical, emotional, and behavioral consequences of sexual abuse; and coordination with other professionals to provide comprehensive treatment and follow-up of victims.

Recomendaciones CEVIHP/SEIP/AEP/PNS respecto al tratamiento antirretroviral en niños y adolescentes infectados por el VIH

OBJECTIVE

To update antiretroviral recommendations in antiretroviral therapy (ART) in HIV-infected children and adolescents.

METHODS

Theses guidelines have been formulated by a panel of members of the Plan Nacional sobre el SIDA (PNS) and the Asociacion Espanola de Pediatria (AEP) by reviewing the current available evidence of efficacy, safety, and pharmacokinetics in pediatric studies. Three levels of evidence have been defined according to the source of data: Level A: randomized and controlled studies; Level B: Cohort and case-control studies; Level C: Descriptive studies and experts' opinion.

RESULTS

When to start ART should be made on an individual basis, discussed with the family, considering the risk of progression according to age, CD4 and viral load, the ART-related complications and adherence. The ART goal is to reach a maximum and durable viral suppression. This is not always possible, even with clinical and immunologic improvement. The difficulties of permanent adherence and side-effects are resulting in a more conservative trend to initiate ART, and to less toxic and simpler strategies. Currently, combinations of at least three drugs are of first choice both in acute and chronic infection. They must include 2 NA 1 1 NN or 2 NA 1 1 PI. ART is recommended in all symptomatic patients and, with few exceptions, in all infants in the first year of life. Older asymptomatic children should start ART according to CD4 count, especially CD4 percentage, that vary with age. Despite potent salvage therapies, it is common not to reach viral undetectability. Therapeutical options when ART fails are scarce due to cross-resistance. The cause of failure must be identified. Occasionally, there exists clinical and/or immunological progression, and a change of therapy with at least two new drugs still active for the patient, is warranted with the aim of increasing the CD4 count to a lower level of risk. Toxicity and adherence must be regularly monitored. Some aspects about post exposure prophylaxis and coinfection with HCV or HBV are discussed.

CONCLUSIONS

A higher level of evidence with regard to ART effectiveness and toxicity in pediatrics is currently available, leading to a more conservative and individualized approach. Clinical symptoms and CD4 count are the main determinants to start and change ART.

Management of occupational and nonoccupational postexposure HIV prophylaxis

The principles of managing patients with recent HIV exposures are similar whether the exposure occurs in an occupational or nonoccupational setting. For both settings, clinicians should 1) assess the likelihood that HIV and other bloodborne viruses will be transmitted as a consequence of the exposure; 2) advise the patient about the risks and benefits of treatment; 3) choose an appropriate antiretroviral treatment regimen (if the decision is made to treat); 4) screen for other illnesses that may complicate treatment or follow-up; 5) counsel patients about the importance of adhering to treatment; 6) promote safe-sex practices and methods to avoid future exposures; 7) follow the patient for potential side effects of treatment; 8) provide follow-up care including repeat HIV testing for seroconversion, surveillance for primary HIV infection, and reinforcement of counseling messages.

Management of the infant born to a mother with HIV infection

In countries with adequate resources, rates of perinatal mother-to-child-transmission (MTCT) of HIV can be as low as 2% or lower. To achieve this low rate of MTCT of HIV requires identification of women with HIV infection early in pregnancy, treatment of the pregnant woman with appropriate combination antiretroviral therapy, special interventions in maternal management during labor and delivery, and appropriate care of the newborn infant. Although many of the steps in preventing HIV MTCT fall to obstetrical care providers, practitioners focused on care of the newborn also play an important role in the prevention of perinatal HIV MTCT, follow-up to identify or exclude HIV infection in the infant, and ongoing care for children and families affected by HIV.