Immunodeficiency Virus Postexposure Prophylaxis Research Articles

Specialty pharmacy interventions benefit patients receiving HIV postexposure prophylaxis

BackgroundSpecialty pharmacies service many different complex disease states that require high-cost medication, including the treatment of patients prescribed human immunodeficiency virus postexposure prophylaxis (PEP). PEP requires time-sensitive initiation and patient counseling for therapeutic efficacy. ObjectiveThis study aimed to examine all PEP referrals received at a specialty pharmacy and demonstrate how they aided in interventions including assisting in obtaining financial assistance, making clinical interventions, and offering counseling to patients. MethodsThis is an observational retrospective chart review of patients who received PEP from one specialty pharmacy. All patients who filled PEP at the pharmacy between January 1, 2017, and July 1, 2022, were included. Information was collected from documentation provided in the electronic medication record used by the pharmacy. The PEP regimen prescribed were raltegravir (RAL) + emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) and dolutegravir (DTG) + FTC/TDF. ResultsA total of 52 patients were treated with PEP during the measurement period. Patients who received a PEP regimen of RAL + FTC/TDF experienced a total cost savings of $1692.60 and $218.40 for those who were fully insured and uninsured, respectively. Patients who received a PEP regimen of DTG + FTC/TDF experienced a total cost savings of $676.20 and $2725.50 for those who were fully insured and uninsured, respectively. Counseling by a pharmacist was offered to all patients and 74.5% of patients accepted. Pharmacists made clinical interventions on 29.4% of PEP referrals. ConclusionPEP medications are expensive and time sensitive and can require clinical interventions and specific patient counseling. This study indicates that specialty pharmacies can provide and ensure access to care in the areas of financial assistance, patient counseling, and clinical interventions.

Adherence to HIV post-exposure prophylaxis in a specialized service in São Paulo, Brazil

Introduction: The effectiveness of human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) depends on adherence to the protocol, which includes taking antiretrovirals (ARVs) and attending visits. We examined the adherence rate to antiretroviral agents and follow-up visits identifying the associated characteristics of adherence and the reasons for not attending HIV PEP consultations in a specialized service in São Paulo, Brazil. Methodology: This was a cross-sectional study with health service users who had an indication for PEP due to sexual exposure in an HIV/AIDS service from April to October 2019. The health service users were followed-up throughout the prophylaxis cycle. Adherence was determined through self-reports on antiretroviral agent use and attendance to follow-up consultations. Results: Association measures were employed to identify adherence-related characteristics. The sample analyzed included 91 users. The mean age was 32.5 years old (SD = 9.8). The largest share was white-skinned (49.5%), men who have sex with other men (62.2%), male (86.8%), and undergraduate/graduate students (65.9%). Adherence totaled 56.7% and health insurance was the associated characteristic (p = 0.039). Work (55.9%), using a private service (15.2%), forgetfulness (11.8%) and considering follow-up unnecessary (11.8%) were the main reasons for not attending the follow-up appointments. Conclusions: Few users do attend HIV PEP consultations. The users without health insurance had the highest adherence percentage whereas work was mentioned as a reason for not attending HIV PEP consultations.

Knowledge, attitude, and practice of human immune-deficiency virus (HIV) post-exposure prophylaxis among healthcare workers of governmental hospitals in Addis Ababa, Ethiopia

This study aimed to investigate the knowledge, attitude, and practice of human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) among healthcare workers in government hospitals in Addis Ababa, Ethiopia. A multicenter, cross-sectional study was conducted from March to April 2022. The lottery method of a simple random sampling technique was used to select six government hospitals. Structured, self-administered questionnaires were used to collect the data, which was coded into Microsoft Excel® and then exported to statistical package for social sciences (SPSS) ®Version 26 for further statistical analysis. A large proportion of respondents (51.6%) and 63.6%) reported poor knowledge and practice respectively, regarding PEP for HIV. However, more than half of respondents (54.2%) had a favorable attitude toward PEP for HIV. A significant proportion of respondents had poor knowledge and practice regarding PEP for HIV, even though they had relatively favorable attitudes. Most healthcare workers (68.9%) did not receive any PEP training.

Knowledge, Attitude and Utilization of HIV Post Exposure Prophylaxis among Health-Care Workers in a Teaching Hospital in Enugu State, South East Nigeria

Background: It is impossible to overstate the significance of Human Immunodeficiency Virus Post-exposure Prophylaxis (HIV PEP), which has demonstrably reduced the risk of getting the fatal disease Acquired Immunodeficiency Syndrome (AIDS). It is crucial for the public health to understand the effects of an HIV infection in a health care worker (HCW). Because of the risks associated with their jobs, these HCWs are more likely to contract an infection.
 Aim: The objective of this study was to assess the knowledge, attitude and utilization of HIV PEP among health care workers in Enugu State University of Science and Technology Teaching Hospital (ESUTH), Parklane, Enugu State. 
 Methodology: This study was a descriptive, cross-sectional study. The sample size was 204 HCWs and 200 questionnaires were returned for analysis. The sample was selected by stratified sampling technique. The data was analyzed using statistical packaged for social science (SPSS). 
 Results: The study revealed that majority of the respondents were within the age range of 26-30and 31-35 years (24.5% each). Majority (65.6%) were married and most (44.0%) were nurses. About 89% have heard of HIV PEP. Almost forty-three percent (42.5%) have been accidentally exposed to needle stick injury before but only 39% reported. Even a less percentage (21%) went ahead to take PEP.
 Conclusion: The study concluded that most of the correspondents were aware of HIV PEP but only a few deemed it necessary to practice what they know. Therefore, there is a great need for health education on the right approach to HIV PEP in this institution and the general population. This will go a long way to help reduce the incidence of HIV infection and improve the utilization of HIV PEP among HCWs in ESUTH.

Administering human immunodeficiency virus post-exposure prophylaxis: challenges experienced by mothers in Lusaka, Zambia.

BackgroundMothers living with human immunodeficiency virus (HIV) should be guided to practise safe childbirth, provide appropriate infant feeding, return infants for repeat HIV testing and administer for the required period, protective antiretroviral (ARV) medication (post-exposure prophylaxis [PEP]) to their infants. Although several studies have explored challenges related to the prevention of mother-to-child transmission (PMTCT), no studies were found that focused specifically on the mother and PEP.ObjectivesTo explore and understand the challenges experienced by mothers in Lusaka, Zambia, whilst providing their children with PEP.MethodsThis study utilised a qualitative methodology and a descriptive design. Fifteen semi-structured individual interviews were conducted with mothers who gave PEP to their infants. Study evaluation made use of Creswell’s six steps of data analysis.ResultsWomen experienced numerous challenges. Challenges of an individual and social nature included ‘negative’ emotions, misconceptions and a lack of understanding of PEP. Post-exposure prophylaxis was sometimes burdensome and partner involvement often limited. Cultural, religious practices and stigma deterred some women from continuing PEP. Healthcare challenges included time-consuming appointments and protracted waiting periods. Clinic organisation was often inefficient and complicated by stock-outs of essential medication such as nevirapine. Healthcare workers were at times stigmatising towards mothers living with HIV and their infants. The counselling support provided by the healthcare workers was felt to be inadequate in the face of the burden of PEP.ConclusionPost-exposure prophylaxis as part of the PMTCT programme is key to eliminating mother-to-child transmission of HIV. Postnatal support for women administering PEP to their children can be enhanced through counselling that is person- and family-centred is culturally sensitive and offers differentiated services that include PEP, integrated mother-and-child healthcare and access to support groups.

HIV Non-Occupational Post-Exposure Prophylaxis Awareness Among Undergraduate Students of a Private University in South-West Nigeria

Objectives: The Human Immunodeficiency virus causes an infection of public health importance with about 71% of the global burden in Sub-Saharan Africa. In Nigeria, 3.2 million people are living with HIV, and 838,000 - 1.3 million of the cases are found among youths. Although Non- Occupational Human Immunodeficiency Virus (HIV) post-exposure prophylaxis (nPEP) is a safe and efficacious method of HIV prevention, it remains an underutilized prevention strategy in Nigeria. This study aimed to determine the awareness level of nPEP after sexual and other non-occupational exposure to HIV among undergraduate students of a private University. Methods: A descriptive cross-sectional survey was conducted among 395 undergraduates’ students. Data was collected by pre-tested structured self-administered questionnaires. Data obtained from the study were analyzed using the IBM SPSS Statistics version 20 software program and Frequency distribution tables with percentages and cross-tables were used for data description. Results: About 42.8% were aware of nPEP. Most of the respondents 361 (91.4%) knew that PEP is to be given after HIV exposure risk following sexual intercourse. Although 79.5% of the respondents indicated that they will see their physician after unprotected sexual intercourse and other non-occupational exposure to HIV, the majority neither knows about nPEP initiation time, 247 (62.5%) nor its duration, 286 (72.4%). Conclusions: A low level of awareness was observed among our study participants, therefore, consistent health education and promotion of nPEP will improve its awareness, uptake, and possibly reduce the prevalence of HIV among our youths.

The South African Nurse’s Knowledge of Occupational Human Immunodeficiency Virus Postexposure Prophylaxis in the Era of Controlled and Stable HIV Prevalence

Knowledge is a crucial aspect of nursing. Nurses, just like any other healthcare workers (HCWs), are empowered with the knowledge of Human Immunodeficiency Virus (HIV) Postexposure Prophylaxis (PEP) protocol to be followed, including post-exposure to blood and body fluids (BBFs). The utilization of HIV PEP demonstrated its capabilities to prevent HCWs from HIV infections. However, the practice in healthcare settings remains a challenge, as many HCWs do not adhere to the protocol. This study investigated how knowledgeable nurses are about HIV PEP in the era of controlled and stable HIV prevalence. Ninety-four nurses completed a self-administered questionnaire to provide information. A biostatistician assisted with data analysis, using Microsoft Excel converted to the STATA 13 format. Most (77.0%) were female with a mean age of 30 ± 9 years. The degree of knowledge was low, although the results showed that 90.43% of nurses had been informed about HIV PEP. Eighty (84%) did not know where to access HIV PEP, and (55.32%) were unaware of HIV PEP guidelines. A comparison between knowledge and work experience revealed that those with five years and less experience are less knowledgeable. There is a need to improve nurses’ knowledge of HIV PEP to reduce the risk of HIV acquisition from work-related activities.

Understanding Oregon’s Public Health and Pharmacy Formulary Advisory Committee

Pharmacists are engaging in a broader array of clinical activities, often necessitating prescriptive authority. As a result, in 2017, Oregon passed House Bill 2397, which directed the Oregon Board of Pharmacy (OBOP) to form the Public Health and Pharmacy Formulary Advisory Committee (PHPFAC). This multidisciplinary committee is charged with making recommendations to the OBOP on a formulary of drugs and devices that a pharmacist may prescribe and dispense pursuant to a diagnosis by a qualified health care provider. The formulary compendium, implemented through statewide protocols, currently provides a pathway for pharmacists to prescribe medications for cough and cold, preventative care, smoking cessation, travel, human immunodeficiency virus postexposure prophylaxis, noncomplicated vulvovaginal candidiasis, and an array of devices and supplies. It also allows a pharmacist to extend a patient’s prescription to avoid therapy interruption. Implementation has been delayed as statutory language required clarification, and it has been challenged by limited reimbursement for clinical consultation. However, the PHPFAC framework provides a novel approach to expand pharmacist prescriptive authority without ongoing legislative action. It also provides a mechanism to engage the pharmacy community in discussions surrounding pharmacist prescribing. Future work is needed to address barriers to implementation.

"Meds-in-Hand" Intervention to Reduce Critical Process Delays in Pediatric Human Immunodeficiency Virus Post-Exposure Prophylaxis.

Pediatric human immunodeficiency virus post-exposure prophylaxis is frequently indicated, but delays in medication receipt are common. Using plan-do-study-act cycles, we developed a multidisciplinary collaboration to reduce critical process delays in our pediatric emergency department. Interruptions decreased from a median 1 per month pre-intervention to zero per month during the intervention.

Occupational exposure to blood and body fluids and use of human immunodeficiency virus post-exposure prophylaxis amongst nurses in a Gauteng province hospital.

BackgroundHealthcare facilities in South Africa are confronted by several challenges arising from Human immunodeficiency virus (HIV) and acquired immune diseases syndrome infection pandemic. All categories of nurses continue to experience accidental occupational exposure to blood and body fluids (BBFs) of patients who are HIV-positive. Studies conducted revealed that nurses fail to report the occurrence of the exposures. This represents a serious challenge because they contract HIV infections whilst in the process of helping others.ObjectivesThe purpose of this study was to determine the occupational exposures and use of HIV post-exposure prophylaxis (PEP) amongst nurses at the selected tertiary academic hospital, Tshwane district, Gauteng province, South Africa.MethodsA quantitative descriptive study was conducted with 94 male and female clinical nurses, using a self-administered questionnaire that facilitated collection of biographical data, occupational exposures to BBFs and use of HIV PEP. The data analysis included univariate and bivariate descriptive analyses.ResultsOf the 94 nurses, n = 40 (43%) had been exposed to BBFs, either through sharp or needle prick injuries or splashes but only 16 (46%) of them reported the incident. Nurses were not keen to report accidental occupational exposures to BBFs in their own facility and rather sought HIV PEP outside their workplace. They gave different reasons for their behaviour. For example, ‘I did not know where to report’.ConclusionOur study highlights the gaps that exist in reporting occupational exposure to BBFs and obtaining HIV PEP. Therefore, we recommend evaluation of these occupational exposures to BBFs and the management thereof, as well as to address the identified problems.

Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors

Background: Healthcare workers (HCWs) are constantly vulnerable to occupational blood and body fluid exposures (OBBFEs). Exposed HCWs experience emotional, physical and psychological trauma. Less experienced HCWs, such as intern doctors, are more prone to OBBFEs. Objectives: The aim of this study was to investigate the prevalence and practices pertaining to OBBFEs amongst a select group of intern doctors in the Gauteng province of South Africa. Methods: A quantitative cross-sectional descriptive study using a questionnaire based on a practical model was used. Intern doctors were recruited from four major hospitals in Gauteng. Results: A total of 175 intern doctors participated in the study. There was a total of 182 (mean = 1.04, standard deviation [s.d] 0.88) reported OBBFEs amongst 136 (77.7%) subjects. The exposures occurred predominantly whilst subjects were working in surgery ( n = 50, 27.5%), obstetrics and gynaecology ( n = 49, 26.9%) and internal medicine ( n = 48, 26.4%) departments; were superficial wounds ( n = 69, 37.9%); were acquired during vascular puncture or intravenous line insertion ( n = 69, 37.9%); and occurred when subjects were working >12 h shifts ( n = 101, 55.5%). Human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) was initiated in 141 (77.5%) out of the 182 exposures. Only 90 (63.8%) subjects completed the recommended 28-day course of PEP. Two (1.1%) subjects reported that they had acquired HIV infection as a consequence of the OBBFE. Conclusion: Occupational blood and body fluid exposures are common amongst intern doctors. It is recommended that regular training, health education and monitoring compliance should be incorporated during the induction of medical intern doctors in hospitals. The availability of PEP regimens with better tolerability will encourage compliance.

Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors.

BackgroundHealthcare workers (HCWs) are constantly vulnerable to occupational blood and body fluid exposures (OBBFEs). Exposed HCWs experience emotional, physical and psychological trauma. Less experienced HCWs, such as intern doctors, are more prone to OBBFEs.ObjectivesThe aim of this study was to investigate the prevalence and practices pertaining to OBBFEs amongst a select group of intern doctors in the Gauteng province of South Africa.MethodsA quantitative cross-sectional descriptive study using a questionnaire based on a practical model was used. Intern doctors were recruited from four major hospitals in Gauteng.ResultsA total of 175 intern doctors participated in the study. There was a total of 182 (mean = 1.04, standard deviation [s.d] 0.88) reported OBBFEs amongst 136 (77.7%) subjects. The exposures occurred predominantly whilst subjects were working in surgery (n = 50, 27.5%), obstetrics and gynaecology (n = 49, 26.9%) and internal medicine (n = 48, 26.4%) departments; were superficial wounds (n = 69, 37.9%); were acquired during vascular puncture or intravenous line insertion (n = 69, 37.9%); and occurred when subjects were working >12 h shifts (n = 101, 55.5%). Human immunodeficiency virus (HIV) post-exposure prophylaxis (PEP) was initiated in 141 (77.5%) out of the 182 exposures. Only 90 (63.8%) subjects completed the recommended 28-day course of PEP. Two (1.1%) subjects reported that they had acquired HIV infection as a consequence of the OBBFE.ConclusionOccupational blood and body fluid exposures are common amongst intern doctors. It is recommended that regular training, health education and monitoring compliance should be incorporated during the induction of medical intern doctors in hospitals. The availability of PEP regimens with better tolerability will encourage compliance.

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.

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.

Determinants of appropriate knowledge on human immunodeficiency virus postexposure prophylaxis among professional health-care workers in Sokoto, Nigeria.

Introduction:The prevention of human immunodeficiency virus (HIV/AIDS) among health-care workers (HCWs) has remained a major topical issue worldwide. Accidental transmission of HIV infection to HCWs during occupational exposure is a real threat today. The study aimed to assess the knowledge, attitude, and practice of postexposure prophylaxis (PEP) among HCWs in a tertiary health institution in Sokoto, Northwestern Nigeria.Methodology:The study was carried out at Usmanu Danfodiyo University Teaching Hospital, Sokoto, through a cross-sectional descriptive study design; a total of 156 participants were recruited using a stratified sampling technique. Data were collected using a semi-structured, self-administered questionnaire and analyzed using SPSS computer software after obtaining ethical clearance from the Health Ethics and Research Committee of the teaching hospital.Results:A total of 87.2% (136) of the respondents had heard of PEP and 71.8% (112) thought that HIV/AIDs could be prevented through PEP. A total of 71.2% (111) had good knowledge about PEP, whereas 86.8% (118) had a positive attitude toward PEP.Conclusion:Although the study demonstrated high knowledge and positive attitude toward PEP, the observance of safety measures against needlestick injuries that could result in HIV infections was abysmally low. There is the need to create more awareness and strengthen the use of PEP protocol by all cadres of health workers as this will go a long way in minimizing blood-borne infections.

Post exposure prophylaxis against human immunodeficiency virus: Awareness knowledge and practice among Nigerian Paediatricians

Objective : To determine the level of awareness, knowledge and practice of human immunodeficiency virus post exposure prophylaxis (HIV PEP) among paediatricians in Nigeria. Methodology : The study was a cross sectional questionnairebased survey conducted among paediatrcians that attended the Paediatric association of Nigeria annual scientific conference in 2015. Results : Most of the respondents (96%) were aware of the concept HIV PEP. The scores on knowledge of PEP for all the respondents ranged from 18% to 91 % with a mean score of 46.5 ± 14.1%. There was no significant difference between the performance of those who had received training on HIV PEP (48.0 ± 13.2%) and those who had not (45.1 ± 14.8%), p = 0.21, t =1.26. Ninety one (60.7%) of the respondents had been exposed to percutaneous injury during work. Thirty (33%) of the exposed paediatricians did not know the patient’s HIV status and only 10 (11%) received PEP, with only 7 (7.7%) of them completing the PEP for 4 weeks Conclusion : Despite the high level of HIV PEP awareness, there was an unacceptable high rate of occupational exposures and poor knowledge of HIV PEP among Paediatricians. Additionally, there was a low uptake of HIV PEP services amongst exposed Paediatricians in Nigeria. There is need for urgent action to curb this trend. Key Words : HIV PEP, Paediatrician, Nigeria

Choice of antiretroviral drugs for postexposure prophylaxis for adults and adolescents: a systematic review.

The choice of preferred regimens for human immunodeficiency virus postexposure prophylaxis (PEP) has evolved over the last 2 decades as more data have become available regarding the safety and tolerability of newer antiretroviral drugs. We undertook a systematic review to assess the safety and efficacy of antiretroviral options for PEP to inform the World Health Organization guideline revision process. Four databases were searched up to 1 June 2014 for studies reporting outcomes associated with specific PEP regimens. Data on PEP completion and discontinuation due to adverse events was extracted and pooled estimates were obtained using random-effects meta-analyses. Fifteen studies (1830 PEP initiations) provided evaluable information on 2-drug regimens (zidovudine [ZDV]- or tenofovir [TDF]-based regimens), and 10 studies (1755 initiations) provided evaluable information on the third drug, which was usually a protease inhibitor. The overall quality of the evidence was rated as very low. For the 2-drug regimen, PEP completion rates were 78.4% (95% confidence interval [CI], 66.1%-90.7%) for people receiving a TDF-based regimen and 58.8% (95% CI, 47.2%-70.4%) for a ZDV-based regimen; the rate of PEP discontinuation due to an adverse event was lower among people taking TDF-based PEP (0.3%; 95% CI, 0%-1.1%) vs a ZDV-based regimen (3.2%; 95% CI, 1.5%-4.9%). For the 3-drug comparison, PEP completion rates were highest for the TDF-based regimens (TDF+emtricitabine [FTC]+lopinavir/ritonavir [LPV/r], 71.1%; 95% CI, 43.6%-98.6%; TDF+FTC+raltegravir [RAL], 74.7%; 95% CI, 41.4%-100%; TDF+FTC+ boosted darunavir [DRV/r], 93.9%; 95% CI, 90.2%-97.7%) and lowest for ZDV+ lamivudine [3TC]+LPV/r (59.1%; 95% CI, 36.2%-82.0%). Discontinuations due to adverse drug reactions were lowest for TDF+FTC+RAL (1.9%; 95% CI, 0%-3.8%) and highest for ZDV+3TC+boosted atazanavir (21.2%; 95% CI, 13.5%-30.0%). The findings of this review provide evidence supporting the use of coformulated TDF and 3TC/FTC as preferred backbone drugs for PEP. Choice of third drug will depend on setting; for resource-limited settings, LPV/r is a reasonable choice, pending the improved availability of better-tolerated drugs with less potential for drug-drug interactions.

Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review.

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. 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. 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. The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates.

End Users’ Views and Preferences on Prescribing and Taking Postexposure Prophylaxis for Prevention of HIV: Methods to Support World Health Organization Guideline Development

The 2014 World Health Organization guidelines for human immunodeficiency virus postexposure prophylaxis (PEP) are the first to combine recommendations for all populations and exposures. To inform the development of these guidelines, we gathered views of end users on key aspects of PEP provision. A mixed-methods approach was used to gather views from the populations for whom the guideline will be of relevance. Data gathered from an online survey, focus group discussions, and previously collected data from in-depth interviews with key populations were used to inform the development of recommendations, in particular where there is a paucity of evidence to assess the benefits and harms of an intervention. This was a successful method to gather end users' views and preferences; however, limitations exist in the generalizability and reliability of the evidence. Future guideline development processes should consider methods to include the views of end users to guide the decision-making process.

Selecting an Antiretroviral Regimen for Human Immunodeficiency Virus Postexposure Prophylaxis in the Occupational Setting

Selecting an Antiretroviral Regimen for Human Immunodeficiency Virus Postexposure Prophylaxis in the Occupational Setting