Indications For Post-exposure Prophylaxis Research Articles

Rabies knowledge gaps and risk behaviour in Dutch travellers: An observational cohort study

BackgroundTravellers visiting rabies-endemic countries are at risk of rabies infection. Assessing travellers’ knowledge and risk perception of rabies and risk behaviour during travel can help identify knowledge gaps and improve pre-travel risk education. MethodsCohort study in Dutch adult travellers, using two surveys: one before travel to assess knowledge and perception of rabies, and one after return to identify risk behaviour during travel. ResultsThe pre-travel and post-travel survey were completed by 301 and 276 participants, respectively. 222 participants had travelled to a high-risk rabies-endemic country. 21.6 % of the participants scored their rabies knowledge as poor. Some participants were unaware cats or bats can transmit rabies (26.6 % and 13.6 %, respectively), or that post-exposure prophylaxis (PEP) is required for certain exposures such as skin abrasions without bleeding or licks on damaged skin (35.5 % and 18.9 %, respectively), while 27.9 % of participants did not know PEP needs to be administered within one day. 115 participants (51.8 %) reported any form of contact with any animal during travel. Two participants reported animal exposure, of which one took adequate PEP measures. Risk factors for animal contact abroad were regularly touching cats or dogs at home or abroad, longer travel duration, having pets during childhood and being an animal lover. ConclusionsPre-travel rabies risk education currently does not meet travellers’ needs, which is reflected in knowledge gaps and engagement in risk behaviour during travel. During pre-travel health advice, avoiding animal contact abroad should be emphasized, and additional education is required about indications for PEP.

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.

Efficiency and relevance of post-exposure prophylaxis prescription by emergency physicians: a monocentric retrospective study

Background: Preventing infection with HIV remains a major public health challenge. Exposed persons are offered support and quick access to the post-exposure prophylaxis (PEP) by hospital emergency services. This study aimed to investigate the accuracy of the prescription of emergency PEP for patients with sexual fluid exposure in a French emergency department (ED) by comparing data in medical files and actual prescriptions. Methods: We retrospectively collected data for patients consulting for sexual exposure in a single Parisian ED from 2015 to 2016. For each patient, researchers independently checked whether the emergency physician prescribed PEP according to French guidelines. Our primary outcome was the appropriateness of the emergency PEP prescription after sexual fluid exposure. We calculated the Cohen weighted kappa coefficient with its 95% confidence interval (CI) for determining the agreement in indication for PEP. Results: We included 346 patients in the analysis. Half of the patients were men who had sex with men (n=178). The most frequent sexual exposure was anal insertive or receptive (n=177; 51%). PEP was prescribed in 94% of cases (n=328). In 33 cases (10%) the indication for PEP was not clear, but PEP was prescribed in 17 cases (52%). The Kappa value for determining the indication for PEP was 0.55 (95% confidence interval 0.36-0.74), indicating poor agreement for prescription. The agreement was lowest for men who had sex with men: 0.29 (0.05-0.53). Conclusion: Strategies are needed to improve the relevance of the prescription of PEP in French EDs to avoid the excess secondary effects and cost.

HIV post-exposure prophylaxis in the Emergency Department: a perspective from Singapore

Background:Exposures to human immunodeficiency virus (HIV) commonly arrive at the Emergency Department (ED) for evaluation of transmission risk and the necessity for post-exposure prophylaxis (PEP). PEP aims to prevent HIV after exposure. International recommendations exist to guide eligibility assessment and standardise prescribing practices.Objective:The primary objective was to describe the patient cohort receiving HIV PEP at the ED. The secondary objective was to assess the ED physicians’ adherence to the 2005 guidelines provided by US Centers for Disease Control and Prevention for HIV PEP.Methods:This retrospective study identified patients prescribed with PEP after presenting with potential HIV exposure to a tertiary hospital ED in Singapore over 2 years. The exposure type and characteristics, source patient characteristics, indications for PEP, HIV status on presentation and on follow-up were assessed. Institutional guidelines recommended tenofovir/emtricitabine (Truvada) and raltegravir as HIV PEP.Results:Twenty-seven patients received HIV PEP during the study period. The majority (81.5%) presented after occupational exposure, with fresh needlestick injury (44.4%) being the most common cause. Amongst all recipients, PEP was indicated in 22.2% and not in 18.5%.Conclusions:With international guidelines simplifying eligibility assessment and prescribing practices, accurate and evidence-based PEP provision should be implemented at the frontline in the ED. These may be encouraged by enforcement of specific workflows and physician education.

859. Same-Day HIV Pre-exposure Prophylaxis (PrEP) Initiation During Drop-in STD Clinic Appointments Is a Safe, Feasible, and Effective Method to Engage Patients at Risk for HIV in PrEP Care

BackgroundPatients at risk for HIV generally do not have immediate access to PrEP. We hypothesized that by offering free, 30-day PrEP starter packs and navigation support during drop-in STD clinic appointments, individuals would be likely to initiate and continue PrEP.MethodsIndividuals aged ≥18 years presenting for drop-in appointments in the Metro Denver STD Clinic and indicated for PrEP were eligible for the study. Exclusion criteria were history of renal dysfunction, chronic hepatitis B (HBV), HIV, pregnancy, and indications for postexposure prophylaxis. Eligible individuals were provided PrEP education and offered a free, 30-day PrEP starter pack and navigation support for cost assistance. Participants were tested for creatinine, HBV, HIV, and pregnancy at enrollment, and navigated to an appointment for ongoing PrEP care. Participants’ medical records were reviewed for a minimum of 4 months after enrollment. Descriptive statistics and logistic regression were used to characterize the study population and follow-up.ResultsFrom April to October 2017, 100 individuals filled a tenofovir–emtricitabine prescription (figure). Median participant age was 28 years, 98% were male, 53% were non-Hispanic White, 8% non-Hispanic Black, and 34% Hispanic. Median annual income was $24,000, 62% had health insurance, 26% had a primary care provider (PCP), and 50% had a recent bacterial STI. No participants had abnormal baseline creatinine or HBV. 77% completed ≥1 PrEP follow-up visit during the study period; 57% completed their first visit within 31 days. 56% completed a second follow-up visit. No HIV seroconversions were detected during follow-up. Factors significantly associated with attending ≥1 follow-up appointment were age ≥ 30 years, higher income, and having health insurance or a PCP at enrollment. In multivariate logistic regression, only higher income was associated with attending ≥1 follow-up appointment (median income for those with ≥1 follow-up visit vs. no follow-up: $24,960 vs. $14,000, P <0.01).ConclusionProviding immediate access to PrEP during drop-in STD clinic visits is a safe and feasible approach to initiation of PrEP care. Additional resources are needed to support PrEP continuity care, particularly for low-income individuals. Disclosures K. Kamis, Gilead Scienes: Research Coordinator, Research grant. S. Rowan, Gilead Sciences: Investigator, Research grant.

High HIV incidence in men who have sex with men attending for postexposure prophylaxis: a service evaluation

Background/aimsThere are limited outcome data for men who have sex with men (MSM) who have received HIV postexposure prophylaxis (PEP). The objective of this service evaluation was to determine HIV...

P74 Post exposure prophylaxis: bashh regional audit 2014

Background/introduction In 2011 British Association of Sexual Health and HIV (BASHH) updated their guidelines on HIV post-exposure prophylaxis (PEP). Aim(s)/objectives To audit the management of patients treated with PEP for both sexual and non-sexual risk in GUM clinics against BASHH PEP guidelines. Methods A retrospective case notes review was performed on patients attending for PEP following both sexual and non-sexual risk, in 7 GUM clinics in Wessex between January–December 2013. Data collected included indication for PEP, time to commence, STI screening, completion rates and HIV testing done at baseline and 3 months post-PEP. Results 98 case notes were reviewed. 77 patients had a sexual risk (47/77 men who have sex with men) and 21 a non-sexual risk. 92% of patients had a baseline HIV test at Conclusion This audit demonstrated some good management such as baseline HIV testing and the time to commence PEP. It also revealed areas to be improved, in particular PEP prescribing in a non-sexual risk situation, where often the risk was not a recommended indication. This highlights the importance of continued education to all PEP prescribers.

Current perspectives in HIV post-exposure prophylaxis.

The incidence of human immunodeficiency virus (HIV) infection continues to rise among core groups and efforts to reduce the numbers of new infections are being redoubled. Post-exposure prophylaxis (PEP) is the use of short-term antiretroviral therapy (ART) to reduce the risk of acquisition of HIV infection following exposure. Current guidelines recommend a 28-day course of ART within 36–72 hours of exposure to HIV. As long as individuals continue to be exposed to HIV there will be a role for PEP in the foreseeable future. Nonoccupational PEP, the vast majority of which is for sexual exposure (PEPSE), has a significant role to play in HIV prevention efforts. Awareness of PEP and its availability for both clinicians and those who are eligible to receive it are crucial to ensure that PEP is used to its full potential in any HIV prevention strategy. In this review, we provide current evidence for the use of PEPSE, assessment of the risk of HIV transmission, indications for PEP, drug regimens, and management of patients started on PEP. We summarize national and international guidelines for the use of PEPSE. We explore the place of PEP within the wider strategy of reducing HIV incidence rates in the era of treatment as prevention and pre-exposure prophylaxis. We also consider the implications of recent data from interventional and observational studies demonstrating significant reductions in the risk of HIV transmission within a serodiscordant relationship if the HIV-positive partner is taking effective ART upon PEP guidelines.

Additional gonorrhea and Chlamydia infections found with rapid follow-up screening in men who have sex with men with an indication for HIV postexposure prophylaxis.

Sexually transmitted infection was found in 16.5% of the men who have sex with men with a postexposure prophylaxis indication. Chlamydia and gonorrhea screening was repeated after 14 days. Among those who were initially sexually transmitted infection negative, 4.1% had chlamydia or gonorrhea. In postexposure prophylaxis-indicated men who have sex with men, repeat chlamydia and gonorrhea screening is advised to diagnose infections not apparent at baseline screening.

Knowledge, attitude and practice of Post-Exposure Prophylaxis (PEP) to HIV among doctors in a Nigerian Tertiary Health Institution

Introduction: The HIV/AIDS pandemic still ranks one of the foremost causes of death in developing world. The present prevalence of HIV/AIDS is 5.0% for Sub-Saharan Africa and the Nigerian figure is 3.01%. The rate of infection of a previously non-infected individual in this sub-region is set at 160,000 individuals daily. With such a high prevalence, it of importance that caregivers and particularly medical doctors arm themselves with sufficient knowledge of postexposure prophylaxis.Design: Cross sectional descriptive study.Participants: The study took place among 81 doctors in a tertiary health institute in Nigeria, the University of Calabar Teaching Hospital.Methodology: A semi-structured questionnaire was administered to the subjects using a random sampling method. These questionnaires highlighted their departments, ages and ranks. Their levels of knowledge and indications for PEP as well as their attitudes to this procedure using a modification of the Likert Attitude Scale were also assessed. There were 15 attitude parameters and each attracted a maximum score of 5 points with a total of 75 points. Respondents were scored and the attitude scores were graded thus; negative attitude - &lt;35 points; bare positive – 36 – 50 points; positive – 51 – 65 points; super-positive - &gt;65 points. The subjects were also given an opportunity to suggest ways of improving on the practice of PEP in their various practices.Results: This showed that the knowledge of PEP was satisfactory, however only about half of the respondents mentioned specific indications for PEP. The doctors’ source of information about PEP was also too medically oriented and not broadminded enough for his position as the decision maker / head of the medical team. Respondents attitude towards PEP was positive and very important suggestions were made for better implementation of PEP.Conclusion: The knowledge of PEP is satisfactory in UCTH, Calabar and issues that need to be addressed in our practice border on of information dissemination and measures aimed at increasing the awareness of PEP in our society.KEYWORDS: Knowledge, Attitude, Post-Exposure Prophylaxis Knowledge, Attitude and Practice of post-exposure prophylaxis to HIV

P3.139 Early Incubating Gonorrhoea and Chlamydia Infections in MSM with an Indication For HIV Post Exposure Prophylaxis (PEP)

IntroductionA PEP indication is an ideal opportunity for safe sex promotion and STI screening. Since 2010 the STI outpatient clinic in Amsterdam, the Netherlands, offers PEP to HIV negative men...

Sorovacinação antirrábica: aspectos epidemiológicos e implicações para a assistência de enfermagem

This study was developed with the purpose to search for relevant knowledge concerning nursing care for individuals exposed to the rabies virus and submitted to post-exposure anti-rabies serovaccination. The authors aimed at evaluating the epidemiological aspects of accidents involving household and wild animals occurring in 2007 and patients assisted at a reference hospital located in the mid-southern region of São Paulo State. They also aimed at identifying the relevance of nurses' actions by describing aspects of care provision. The method adopted was exploratory, retrospective and descriptive of the epidemiological aspects of the accidents and of the care provided to these patients by referring to information in their medical charts. Fifty-one charts of patients aged 17 to 81 years, considered to be at risk and with indication for post-exposure prophylaxis against human rabies were evaluated. It was found that nursing care provision to these patients presents low complexity although it requires properly trained professionals. It was possible to identify the relevance of nurses' actions in care provision and procedures related to anti-rabies prophylaxis; however, consistent information concerning nursing care was not observed.

The Trap

The Centers for Disease Control and Prevention, national public health agencies, and an expert committee of the European Commission have recently published updated guidelines on postexposure prophylaxis (PEP) of occupational human immunodeficiency virus (HIV) exposure. 1,2 Management of occupational HIV exposure relies heavily on HIV antibody testing of the source patient. However, patients with acute HIV infection may be antibody negative yet particularly contagious because of high viremia. We report 2 cases involving health care workers who were exposed to patients with acute primary HIV infection (PHI). The patients were in the window period of seroconversion, during which detection of HIV p24 antigen provided the definitive indication for PEP. We also review the literature on the topic.

Pediatric HIV in the Emergency Department

HIV-infected children and youth will continue to be seen in emergency settings. Clinical recognition of patients possibly infected with HIV and the use of rapid HIV testing to identify them are of paramount importance. Effective management of patients known to be infected with HIV requires an understanding of appropriate infection control procedures, an appreciation of risk for opportunistic processes based upon patients' CD4+ T-cell counts, and access to consultation with expert HIV care providers. Finally, effectiveness of and indications for postexposure prophylaxis after occupational and nonoccupational exposures must be appreciated by emergency care providers.

Risk of Rabies Infection and Adverse Effects of Postexposure Prophylaxis in Healthcare Workers and Other Patient Contacts Exposed to a Rabies Virus–Infected Lung Transplant Recipient

Rabies virus was inadvertently transmitted to a lung transplant recipient through donor lungs. The patient was given ventilatory assistance and cared for postoperatively for 6 weeks before a diagnosis of rabies virus infection was made. Postexposure prophylaxis (PEP) was offered to potentially exposed healthcare workers (HCWs). Only HCWs classified as belonging to possible and/or proven contact groups (according to a standardized interview) received PEP. The risk of individual HCWs being exposed to rabies virus was reassessed on the basis of viral concentrations measured in the patient's excretions and body fluids. HCWs who were vaccinated as part of PEP were followed up prospectively according to a standardized procedure. Of 179 HCWs and other patient contacts, 132 met the eligibility criteria for PEP (118 [89.4%] with possible contact and 14 [10.6%] with proven contact with the patient's excretions and/or body fluids). One hundred thirty-one individuals started PEP, and 126 met the inclusion criteria for analysis. Of these, 48 (38%) developed at least 1 adverse effect (8 [6.3%] had fever, 37 [29.4%] had headache, 3 [2.4%] had lymphadenopathy, 17 [13.5%] had dizziness, and 6 [4.8%] had paresthesia). No HCW or other patient contact developed rabies or serious PEP-related adverse effects. Reassessment of the individual's risk of infection as a function of the viral concentration in the patient's excretions and/or body fluids (up to 5.12 x 10(7) copies/mL) revealed that 103 HCWs (78.0%) had contact with high-risk substances (89 [67.40%] had possible contact and 14 [10.7%] had proven contact). HCWs can be exposed to significant viral concentrations in excretions and/or body fluids from rabies virus-infected lung transplant recipients. Because widespread use of PEP entails the possibility of significant health problems for HCWs considered to be at risk of contracting rabies, applying a rational indication for PEP is crucial.

Preventing AIDS: The British Experience

The UK is described by the Department of Health in London as “a relatively low prevalence country for HIV infection.” The word “relatively” is the key. By comparison with the huge numbers of cases seen in much of sub-Saharan Africa, for example, HIV/AIDS is a minor problem in the UK. However, that is no grounds for complacency, as shown by the need for an official target for further reduction, which is a 25% decrease in new diagnoses of HIV infection by the end of 2007. To see how achievable this might be, we need to look at the ways in which new cases are currently arising. Last year saw 7,750 new diagnoses of HIV infection in the UK, but the more detailed breakdown is available up to the end of 2004.1 As of Dec 31, 2004, there were an estimated 58,300 people over the age of 15 years living with HIV in the UK, and this number is rising not only because of new diagnoses but also because of successful anti-HIV drug regimens. Male-to-male transmission remains an issue, at a plateau of around 1,800 new diagnoses annually. Heterosexual intercourse accounts for 4,000 new diagnoses each year, but most of those are acquired outside the UK. Injecting drug use accounts for just 150 new cases; mother-to-child transmissions number only 130 or so (the introduction of antenatal testing as a routine will have helped here); HIV infection due to blood transfusions or blood products is now very rare, most cases being acquired overseas; occupational HIV exposure is also very uncommon. Clearly the 2007 target (i.e., 25% decrease in new diagnoses) can be met only by making a significant impact on the two main sources, which are HIV transmission via same sex or heterosexual intercourse. The early willingness of British health officials and politicians to recognise the potential danger of HIV and do something about it when the world found out about this virus more than 20 years ago explains much of the early success. Still, as elsewhere in the world, pendulums swing back and prevention messages need repeating, especially now that anti-retroviral drugs mean that HIV infection is no longer seen as a death sentence, at least in countries such as the UK where such treatment is affordable. However, public health guidance and policy needs sensitive handling because so many British cases of HIV infection are either acquired outside the country or arise in ethnic minority groups, and more generally, it is difficult to see how prevention can be further enhanced in the UK other than by reinforcement of existing advice. The budget statement in April 2006 did contain a tax concession on condoms, by which the value added tax (a sort of sales tax) would be only 5% instead of the typical 17.5%. Though generally welcomed, this looks like a cosmetic gesture. The non-use of condoms is hardly likely to be based on price. More controversial is post-exposure prophylaxis (PEP). When exposure has been occupational (eg, a needlestick accident involving a healthcare worker) the British PEP guideline is clear, but the same document1 appears more tentative when it comes to exposure via sexual intercourse. This guidance, from February 2004, is currently being revised, but the British Association for Sexual Health and HIV has lately issued its own advice. That guideline2 recommends, provided the source individual is known to be HIV positive, PEP where the exposure has been due to receptive or insertive anal or vaginal sex. As with the U.S. guidelines,3 a further proviso is that the exposure is not more than 72 hours old. The indications for PEP are still being debated, and there is the potential to make some impact on prevention. However, any impression on national HIV statistics will be lessened by the simple fact that so many people who are HIV positive are not aware of their status.

Characterization of medical errors in initiation of postexposure prophylaxis in sexual assault victims in the emergency department

Study objectives: We characterize common medical errors when postexposure prophylaxis (PEP) is initiated to prevent HIV transmission after sexual assault. Methods: This was a retrospective review of cases of sexual assault presenting to a university urban emergency department (ED) from November 2002 to November 2003. The ED has existing guidelines specifying the indications for PEP, as well as the criteria for high-risk cases in which a protease inhibitor should be added to the standard regimen of Combivir for 30 days. The guidelines also state that PEP should be initiated only within 72 hours. Using the guidelines as a standard, 2 trained abstractors reviewed each case and determined whether PEP was indicated and the correct drug regimen. Type and time of exposure, medications given, laboratory studies, and follow-up arrangements were recorded. A κ coefficient was calculated. Results: Sixty-eight cases were reviewed. Mean age of the patients was 24.2 years. Fifty-seven patients presented fewer than 72 hours after the assault; 11 patients presented outside the treatment window for PEP. According to type and time of exposure, PEP was indicated in 51 (75%) of 68 cases. PEP was offered 41 of 51 times it was indicated (80%). Four patients received PEP outside of the 72-hour window. Seven patients refused PEP. Of the remaining 38 patients receiving PEP, the correct drug regimen was given 29 times (76%), and the incorrect regimen was prescribed 9 times (24%). One patient did not have blood drawn for baseline laboratory test levels. The assessment of the HIV status of the assailant was not documented in any case. Of the patients offered PEP, only 24 (53%) of 45 were given documented follow-up instructions. The κ coefficient was 1. Conclusion: Despite department guidelines, errors in initiating PEP after sexual assault were common. Because effective PEP involves a strict adherence to a regimen and close follow-up, we are now studying the effectiveness of a real-time computerized prompt referring the physician to the PEP recommendations.

Spare non-occupational HIV post-exposure prophylaxis by active contacting and testing of the source person.

HIV-1 post-exposure prophylaxis (PEP) is frequently prescribed after exposure to source persons with an undetermined HIV serostatus. To reduce unnecessary use of PEP, we implemented a policy including active contacting of source persons and the availability of free, anonymous HIV testing ('PEP policy'). All consultations for potential non-occupational HIV exposures i.e. outside the medical environment) were prospectively recorded. The impact of the PEP policy on PEP prescription and costs was analysed and modelled. Among 146 putative exposures, 47 involved a source person already known to be HIV positive and 23 had no indication for PEP. The remaining 76 exposures involved a source person of unknown HIV serostatus. Of 33 (43.4%) exposures for which the source person could be contacted and tested, PEP was avoided in 24 (72.7%), initiated and discontinued in seven (21.2%), and prescribed and completed in two (6.1%). In contrast, of 43 (56.6%) exposures for which the source person could not be tested, PEP was prescribed in 35 (81.4%), P < 0.001. Upon modelling, the PEP policy allowed a 31% reduction of cost for management of exposures to source persons of unknown HIV serostatus. The policy was cost-saving for HIV prevalence of up to 70% in the source population. The availability of all the source persons for testing would have reduced cost by 64%. In the management of non-occupational HIV exposures, active contacting and free, anonymous testing of source persons proved feasible. This policy resulted in a decrease in prescription of PEP, proved to be cost-saving, and presumably helped to avoid unnecessary toxicity and psychological stress.