Human Immunodeficiency Virus Postexposure Prophylaxis Research Articles

Factors Influencing Human Immunodeficiency Virus Postexposure Prophylaxis Requests after Low-Risk Occupational Exposure

To determine the factors influencing human immunodeficiency virus postexposure prophylaxis (PEP) requests after "low-risk" occupational exposure. We analyzed data from low-risk occupational exposures reported between January 1999 and May 2000. A total of 318 low-risk occupational exposures were reported. No worker demographic variable, exposure method, or exposure type was associated with increased PEP requests. Exposed workers were more likely to request PEP if the source patient was unknown or 18 to 49 years old. No other source patient demographic variable was associated with increased PEP requests. We found that workers who experienced a low-risk occupational exposure were more likely to request PEP when the source patient was unknown or 18 to 49 years of age. No other factors were associated with increased PEP requests.

One-year study of occupational human immunodeficiency virus postexposure prophylaxis.

A 12-month experience with human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) in a tertiary care center was evaluated for timeliness of treatment and adherence to treatment recommendations. Forty-six health care workers were started on HIV PEP. Risk status of the source patient, rather than type of exposure, was a significant determinant for both initiating and completing treatment. Of those exposed to HIV-positive sources, 79% completed the full 28 days of therapy. Only 22% of all health care workers who started PEP discontinued treatment because of adverse effects. Excluding three cases with significant delays in reporting and one in which treatment was controversial, the mean time from exposure to first dose of PEP was 1 hour and 46 minutes. The use of a defined treatment protocol, with supporting educational material and PEP medication immediately available, is an effective way of managing HIV exposures.

Human Immunodeficiency Virus Postexposure Prophylaxis for Adolescents and Children

Children and adolescents are at risk for human immunodeficiency virus (HIV) infection. Transmission occurs through perinatal exposures, injecting drug use, consensual and nonconsensual sex, needle-stick and sharp injuries, and possibly some unusual contacts. Youth engaging in high-risk sexual activities are especially endangered. Half of the estimated worldwide 5.3 million new HIV infections occur in adolescents and young adults aged 15 to 24. Of 20 000 known new adult and adolescent cases in the United States, 25% involve 13- to 21-year-olds. More than 1.4 million children worldwide (aged 15 and younger) are believed to be infected, and >1640 new cases are diagnosed daily. Of the 432 000 people reported to be living with HIV or acquired immunodeficiency syndrome (AIDS) in the United States, 5575 are children under 13. HIV postexposure prophylaxis (PEP) is a form of secondary HIV prevention that may reduce the incidence of HIV infections. HIV PEP is commonly conceived of as 2 types: occupational and nonoccupational. Occupational HIV PEP is an accepted form of therapy for health care workers exposed to HIV through their jobs. A landmark study of healthcare workers concluded that occupational HIV PEP may be efficacious. Well-established US national guidelines for occupational HIV PEP exist for this at-risk population. Nonoccupational HIV PEP includes all other forms of HIV PEP, such as that given after sexual assault and consensual sex, injecting drug use, and needle-stick and sharp injuries in non-health care persons. Pediatric HIV PEP is typically the nonoccupational type. The efficacy of nonoccupational HIV PEP is unknown. The presumed efficacy is based on a collection of animal and human data concerning occupational, perinatal, and nonoccupational exposures to HIV. In contrast to occupational HIV PEP, there are no national US guidelines for nonoccupational HIV PEP, and few recommendations are available for its use for adolescents and children. Regardless of this absence, there is encouraging evidence supporting the value of HIV PEP in its various forms in pediatrics. Although unproven, the presumed mechanism for HIV PEP comes from animal and human work suggesting that shortly after an exposure to HIV, a window period exists during which the viral load is small enough to be controlled by the body's immune system. Antiretroviral medications given during this period may help to diminish or end viral replication, thereby reducing the viral inoculum to a more potentially manageable target for the host's defenses. HIV PEP is accepted practice in the perinatal setting and for health care workers with occupational injuries. The medical literature supports prescribing HIV PEP after community needle-stick and sharp injuries and after sexual assault from sources known or likely to be HIV-infected. HIV PEP after consensual unprotected intercourse between HIV sero-opposite partners has had growing use in the adult population, and can probably be utilized for children and adolescents. There is less documented experience and support for HIV PEP after consensual unprotected intercourse between partners of unknown HIV status, after prolonged or multiple episodes of sexual abuse from an assailant of unknown HIV status, after bites, and after the sharing of personal hygiene items or exposure to wounds of HIV-infected individuals. There are no formal guidelines for HIV PEP in adolescents and children. A few groups have commented on its provision in pediatrics, and some preliminary studies have been released. Our article provides a discussion of the data available on HIV transmission and HIV PEP in pediatrics. In our article, we propose an HIV PEP approach for adolescents and children. We recommend a stratified regimen, based on the work of Gerberding and Katz and other authors, that attempts to match seroconversion risk with an appropriate number of medications, while taking into account adverse side-effects and the amount of information that is typically available upon initial presentation. Twice daily regimens should be used when possible, and may improve compliance. HIV PEP should be administered within 1 hour of exposure. We strongly recommend that physicians trained in this form of therapy review the indications for HIV PEP within 72 hours of its provision. We advocate that due diligence in determining level of risk and appropriateness of drug selection be conducted as soon as possible after an exposure has occurred. When such information is not immediately available, we recommend the rapid treatment using the maximum level of care followed by careful investigation and reconsideration in follow-up or whenever possible. HIV PEP may be initiated provisionally after an exposure and then discontinued if the exposure source is confirmed to not be HIV-infected. In most cases, consultations with the experts in HIV care can occur after the rapid start of therapy. (ABSTRACT TRUNCATED)

Prophylaxis against possible human immunodeficiency virus exposure after nonoccupational needlestick injuries or sexual assaults in children and adolescents.

Nonoccupational human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) for adults has been described, although the Centers for Disease Control and Prevention, Atlanta, Ga, offer no specific recommendations. There is limited information about its use in children and adolescents. To describe the current practices of physicians in pediatric infectious disease (PID) and pediatric emergency medicine (PEM) departments regarding nonoccupational HIV PEP for children and adolescents. Survey. Directors of all PID and PEM departments with fellowship programs in the United States and Canada between July and November 1998. General questions regarding HIV PEP and questions concerning 2 scenarios (5-year-old with a needlestick injury and a 15-year-old after sexual assault). The return rate was 67 (78%) of 86 for PID and 36 (75%) of 48 for PEM physicians. Fewer than 20% of physicians reported institutional policies for nonoccupational HIV PEP; 33% had ever initiated nonoccupational HIV PEP. In both scenarios, PID physicians were more likely than PEM physicians to recommend or offer HIV PEP in the first 24 hours after the incident (55 [83%] of 66 vs 20 [56%] of 36 for needlestick injuries [odds ratio, 4.0; 95% confidence interval, 1.6-10.1] and 47 [72%] of 65 vs 16 [50%] of 32 for sexual assault [odds ratio, 2.6; 95% confidence interval, 1.1-6.3]). Seven different antiretroviral agents in single, dual, or triple drug regimens administered for 2 to 12 weeks were suggested. Although few physicians reported institutional policies, and only one third had ever initiated HIV PEP, many would offer or recommend HIV PEP for children and adolescents within 24 hours after possible HIV exposure. A wide variation of regimens have been suggested. There is a need for a national consensus for nonoccupational HIV PEP.

Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV Postexposure Prophylaxis Registry.

To collect information about the safety of taking antiretroviral drugs for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP). A voluntary, confidential registry. Hospital occupational health clinics, emergency departments, private physician offices, and health departments in the United States. 492 healthcare workers (HCWs) who had occupational exposures to HIV, were prescribed HIV PEP, and agreed to be enrolled in the registry by their healthcare providers were prospectively enrolled in the registry. Three hundred eight (63%) of 492 of the PEP regimens prescribed for these HCWs consisted of at least three antiretroviral agents. Of the 449 HCWs for whom 6-week follow-up was available, 195 (43%) completed the PEP regimen as initially prescribed. Forty-four percent (n=197) of HCWs discontinued all PEP drugs and did not complete a PEP regimen. Thirteen percent (n=57) discontinued > or =1 drug or modified drug dosage or added a drug but did complete a course of PEP Among the 254 HCWs who modified or discontinued the PEP regimen, the two most common reasons for doing so were because of adverse effects attributed to PEP (54%) and because the source-patient turned out to be HIV-negative (38%). Overall, 340 (76%) HCWs with 6-week follow-up reported some symptoms while on PEP: nausea (57%), fatigue or malaise (38%), headache (18%), vomiting (16%), diarrhea (14%), and myalgias or arthralgias (6%). The median time from start of PEP to onset of each of the five most frequently reported symptoms was 3 to 4 days. Only 37 (8%) HCWs with 6-week follow-up were reported to have laboratory abnormalities; review of the reported abnormalities revealed that most were unremarkable. Serious adverse events were reported to the registry for 6 HCWs; all but one event resolved by the 6-month follow-up visit. Fewer side effects were reported by HCWs taking two-drug PEP regimens than by HCWs taking three-drug PEP regimens. Side effects from HIV PEP were very common but were rarely severe or serious. The nature and frequency of HIV PEP toxicity were consistent with information already available on the use of these antiretroviral agents. Clinicians prescribing HIV PEP need to counsel HCWs about PEP side effects and should know how to manage PEP toxicity when it arises.

Cost effectiveness of human immunodeficiency virus postexposure prophylaxis for healthcare workers.

The United States Public Health Service (USPHS) published recommendations for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) of healthcare workers in May 1998. The aim of this study was to analyse the cost effectiveness of the USPHS PEP guidelines. This was a modelling study in the setting of the US healthcare system in 1989. The analysis was performed from the societal perspective; however, only HIV healthcare costs were considered and health-related losses of productivity were not included. A decision tree incorporating a Markov model was created for 4 PEP strategies: the current USPHS recommendations, triple drug therapy, zidovudine monotherapy or no prophylaxis. A probabilistic sensitivity analysis using a Monte Carlo simulation was performed. Confidence intervals (CIs) around cost-effectiveness estimates were estimated by a bootstrapping method. The costs (in 1997 US dollars) per quality-adjusted life-year (QALY) save by each strategy were as follows: monotherapy $US688 (95% CI: $US624 to $US750); USPHS recommendations $US5211 (95% CI: $US5126 to $US5293); and triple drug therapy $US8827 (95% CI: $US8715 to $US8940). The marginal cost per year of life saved was: USPHS recommendations $US81 987 (95% CI: $US80 437 to $US83 689); triple drug therapy $US970 451 (95% CI: $US924 786 to $US 1 014 429). Sensitivity testing showed that estimates of the probability of seroconversion for each category of exposure were most influential, but did not change the order of strategies in the baseline analysis. With the prolonged HIV stage durations and increased costs associated with recent innovations in HIV therapy, the marginal cost effectiveness of the USPHS PEP strategy was decreased to $US62 497/QALY saved. All 3 intervention strategies were cost effective compared with no postexposure prophylaxis. Current USPHS PEP recommendations are marginally cost effective compared with monotherapy, but the additional efficacy of triple drug therapy for all risk categories is rewarded by only a small reduction in HIV infections at great expense. For the foreseeable future, assuming innovations in therapy that employ expensive drug combinations earlier in the HIV disease course to extend life expectancy and the increasing prevalence of HIV drug resistance, our model supports the use of the USPHS PEP guidelines.

The use of human immunodeficiency virus postexposure prophylaxis after successful artificial insemination

A case is reported of a woman who was exposed to human immunodeficiency virus through self-insemination. She was artificially inseminated with fresh semen obtained from a gay man in whom HIV seroconversion was taking place. Postexposure prophylaxis with antiretrovirals was initiated 10 days later, and despite successful conception, HIV infection was not established. A healthy male infant was subsequently delivered with no obvious toxicity related to medication. (Am J Obstet Gynecol 1999;181:760-1.)

Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault

Although the 1998 Centers for Disease Control and Prevention’s guidelines for treatment of sexually transmitted diseases recommend offering postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault, there are no detailed protocols on how to provide this treatment. Postexposure prophylaxis has been shown to lower the risk of seroconversion following occupational exposure to HIV by 81%, but has not yet been evaluated following sexual exposure. Though scientific data are limited, victims of sexual assault should be given the best information available to make an informed decision regarding postexposure prophylaxis. When the choice is made to take medications to prevent HIV infection, treatment should be initiated as soon as possible, but no later than 72 hours following the assault, and should be continued for 28 days. HIV postexposure prophylaxis should be provided in the context of a comprehensive treatment and counseling program that recognizes the physical and psychosocial trauma experienced by victims of sexual assault.

Occupational exposure to HIV: experience at a tertiary care center.

We examined our hospital-based occupational health clinic's experience with combination antiretroviral therapy for postexposure prophylaxis for human immunodeficiency virus (HIV). Over a 12-month period, 68 workers started postexposure prophylaxis: 23 with zidovudine and lamivudine and 45 with zidovudine, lamivudine, and indinavir. Fifty-one (75%) of the 68 workers starting postexposure prophylaxis reported one or more side effects. Side effects were more common among those taking three drugs. Many workers failed to complete the recommended 28-day regimen because of the side effects of the various treatments. The estimated mean cost for evaluations, prophylaxis, and monitoring of exposed workers was $669 per reported exposure. In our experience, major challenges in carrying out the current HIV postexposure prophylaxis guidelines include expeditious source testing, improved staff education and prevention measures, and scrupulous monitoring of workers taking combination antiretroviral drugs for postexposure prophylaxis, with consideration of alternate regimens for intolerant workers.

Guidelines for Prophylaxis Following Occupational Exposures to HIV

Objective: To review the latest recommendations of the Public Health Service (PHS) regarding human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) in health care workers occupationally exposed to the virus. Data Sources: MEDLINE search of the years 1985 to 1997 for the terms HIV-1 and prophylaxis. Additional articles were identified in the reference lists of articles found in the MEDLINE search. Study Selection: Clinical trials and review articles on efficacy, dosage, adverse effects, and toxicity of the various agents employed in HIV PEP. Data Extraction: Performed by the authors. Data Synthesis: Information regarding HIV PEP is limited. Controlled clinical trials usually involve small populations and are difficult to extrapolate to larger populations. PHS has reviewed the available literature and revised its recommendations for HIV PEP, and these are presented in this article. Conclusion: Until more studies are conducted, the controversy surrounding PEP therapy is likely to continue. Clinicians must continue to balance the use of PEP therapy with the overuse of antiretroviral medications so that resistance is kept to a minimum. Health care professionals must be sensitized to the issues surrounding the use of PEP therapy so that colleagues exposed to HIV on the job can receive comprehensive medical and pharmaceutical care.

Antiviral Chemoprophylaxis After Occupational Exposure to Human Immunodeficiency Virus: Why, When, Where, and What

To update ophthalmologists on recent developments in the area of antiviral chemoprophylaxis after occupational exposure to human immunodeficiency virus (HIV). Background information is provided by which to make an informed decision about whether to initiate antiviral chemoprophylaxis against HIV infection. We discuss why HIV postexposure prophylaxis should be considered; when prophylaxis should be initiated; where prophylaxis medications should be located in the operating or emergency room; and what medications might be used and the factors influencing their selection. Recent provisional recommendations by the United States Centers for Disease Control and Prevention and the International AIDS Society-USA are reviewed along with literature dealing with antiviral chemoprophylaxis against HIV infection. Recommendations are made for specific antiviral chemoprophylaxis after occupational exposure to HIV based on the Centers for Disease Control and Prevention and the International AIDS Society-USA provisional recommendations. Uncertain areas and the minor discrepancies in these two reports are discussed. Prevention of HIV transmission after accidental occupational exposure is possible. Combination therapy is more effective than monotherapy in treating HIV infections. Zidovudine (AZT or ZDV) is effective in postexposure prophylaxis; the combination of zidovudine and lamivudine (3TC) and indinavir (IDV) has greater antiretroviral activity than zidovudine alone does. The requirements for effective HIV postexposure prophylaxis may be somewhat different than those for optimum HIV treatment in the chronically ill HIV-positive patient. Ophthalmologists should have an in-depth knowledge of current thinking regarding HIV pathophysiology and treatment.