Post-Exposure Prophylaxis of HIV Infection in Healthcare Workers: Recommendations for the European Setting

The European Commission funded a project for the standardisation of the management of occupational exposures to HIV/blood-borne infections and antiretroviral post-exposure prophylaxis (PEP) in Europe. Within this project, the following recommendations and rationale were formulated by experts representative of participating countries. Based on assessment of the exposure, material, and source characteristics, PEP should be started as soon as possible with any triple combination of antiretrovirals approved for the treatment of HIV-infected patients; initiation is discouraged after 72 hours Rapid HIV testing of the source could reduce inappropriate PEP. HIV testing should be performed at baseline, 4, 12, and 24 weeks, with additional clinical and laboratory monitoring of adverse reactions and potential toxicity at week 1 and 2. HIV resistance tests in the source and direct virus assays in the exposed HCW are not recommended routinely. These easy-to-use recommendations seek to maximise PEP effect while minimising its toxicity and inappropriate use.     

Transmission of drug-resistant HIV after an occupational exposure despite postexposure prophylaxis with a combination drug regimen.

We documented a case of occupational human immunodeficiency virus (HIV) despite postexposure prophylaxis (PEP) with a combination drug regimen after percutaneous injury with a needle from a sharps disposal container in the hospital room of an HIV-infected patient. This failure of PEP with a combination drug regimen may have been related to antiretroviral drug resistance, other factors, or both. This case highlights the importance of preventing injury to prevent occupational transmission of HIV.     

Investigation of a new diagnosis of multidrug-resistant, dual-tropic HIV-1 infection--New York City, 2005

In December 2004, infection with a strain of multidrug-resistant (MDR), dual-tropic human immunodeficiency virus (HIV)-1 was newly diagnosed in a man aged 46 years in New York City (NYC). The man (i.e., the index patient) had no history of antiretroviral treatment and reported having sex with multiple named and anonymous male partners, using crystal methamphetamine, and engaging in unprotected insertive and receptive anal intercourse. He had rapid progression to acquired immunodeficiency syndrome (AIDS) after experiencing signs and symptoms of acute HIV infection. The case was reported to the New York City Department of Health and Mental Hygiene (NYCDOH) in late January 2005 and has been described previously. This report describes the public health investigation of the index patient's reported contacts and a review of viral genetic sequencing (genotype) results from other HIV-infected patients in the NYC region to estimate the prevalence of this strain of HIV. The investigation, conducted by NYCDOH, Connecticut Department of Public Health, Aaron Diamond AIDS Research Center, New York State Department of Health, and CDC, identified three other patients with similar risk factors who engaged in high-risk sexual activity at the same time and in the same venues as the index patient and who were infected with a genotypically homologous strain of HIV. The findings demonstrate the usefulness of population-based reporting of HIV genotyping data to identify exact matches of new HIV mutations associated with drug resistance and to determine their characteristics and public health importance. The findings also demonstrate the continued risk for HIV transmission among men who have sex with men (MSM) through high-risk behaviors and the need to find effective methods to prevent HIV transmission in this population.     

Post-exposure prophylaxis following exposure to HIV: adaptation to the situation may be indicated

A woman aged 36 injured herself on a needle that had been used to take an iliac-crest biopsy from an HIV-positive patient and a man aged 34 and a woman aged 35 had sexual contact with their HIV-positive partners during which the condom tore. They were given post-exposure prophylaxis (PEP) which was formulated using medication and virus resistance data from the HIV-positive individual. At 3 and 6 months the patients were all still HIV-negative. After occupational or non-occupational exposure to HIV, PEP is initiated if there is a reasonable risk of transmission of HIV. In The Netherlands a combination of 3 antiretroviral drugs is advised based on demonstrated antiviral effectiveness in the regular treatment of HIV-infections. Frequently a standard PEP-regimen is prescribed. If the source patient has a history of antiretroviral therapy, the virus might be resistant to standard PEP-regimens. In these cases the choice of drugs in the PEP-regimen can be individualised based on the antiretroviral medication history of the source patient and known resistance patterns of the source virus.     

Costs of management of occupational exposures to blood and body fluids.

OBJECTIVE: To determine the cost of management of occupational exposures to blood and body fluids. DESIGN: A convenience sample of 4 healthcare facilities provided information on the cost of management of occupational exposures that varied in type, severity, and exposure source infection status. Detailed information was collected on time spent reporting, managing, and following up the exposures; salaries (including benefits) for representative staff who sustained and who managed exposures; and costs (not charges) for laboratory testing of exposure sources and exposed healthcare personnel, as well as any postexposure prophylaxis taken by the exposed personnel. Resources used were stratified by the phase of exposure management: exposure reporting, initial management, and follow-up. Data for 31 exposure scenarios were analyzed. Costs were given in 2003 US dollars. SETTING: The 4 facilities providing data were a 600-bed public hospital, a 244-bed Veterans Affairs medical center, a 437-bed rural tertiary care hospital, and a 3,500-bed healthcare system. RESULTS: The overall range of costs to manage reported exposures was $71-$4,838. Mean total costs varied greatly by the infection status of the source patient. The overall mean cost for exposures to human immunodeficiency virus (HIV)-infected source patients (n=19, including those coinfected with hepatitis B or C virus) was $2,456 (range, $907-$4,838), whereas the overall mean cost for exposures to source patients with unknown or negative infection status (n=8) was $376 (range, $71-$860). Lastly, the overall mean cost of management of reported exposures for source patients infected with hepatitis C virus (n=4) was $650 (range, $186-$856). CONCLUSIONS: Management of occupational exposures to blood and body fluids is costly; the best way to avoid these costs is by prevention of exposures.     

Evaluating supervised haart in late-stage HIV among drug users: A preliminary report

Objective To examine response to highly active antiretroviral therapy (HAART) among a sample of treatment-experienced patients in the late stage of human immunodeficiency virus (HIV) infection in residential health care facilities (RHCFs) in New York City facilities designated for HIV/AIDS (acquired immunodeficiency syndrome) when access and adherence are maximized. Methods Medical record review of 111 patients. Results Demographics were mean age 42 years; 58% male; 60% African-American; 31% Hispanic; 57% injection drug users (IDUs); 23% with history of dementia; 52% hepatitis C virus (HCV) antibody seropositive; 80% on HAART, of whom 18% had lipodystrophy. Of 88 patients on HAART, 52% had a decreased viral load (>1/2log) versus 13% of 23 not on HAART (P<.05); a>1/2log viral load increase was seen in 8% and 35%, respectively (P<.05). Those with viral load increase were more likely than those with stable/decreased viral load to be IDUs (71% vs. 64%) and to have HCV seropositivity (86% vs. 53%), even with similar initial CD4⁺ cell count, viral load, and follow-up time. Conclusion In a predominantly minority IDU population who are treatment experienced, 50% of the patients successfully responded to treatment with supervised therapy. The RHCFs in New York City provide a unique opportunity to examine further factors associated with response to HAART in an environment in which medication administration and adherence are maximized and monitored carefully. Dr. Berkman is from Columbia University/Highbridge Woodycrest Residential Health Care Facility. Ms. Astemborski is from the Johns Hopkins School of Hygiene and Public Health. Supported by the New York Academy of Medicine.     

Co-located Substance Use Treatment and HIV Prevention and Primary Care Services,New York State, 1990–2002: A Model for Effective Service Delivery to a High-Risk Population

The New York State Department of Health (NYSDOH) AIDS Institute (AI) began an initiative in 1990 in collaboration with the Office of Alcoholism and Substance Abuse Services (OASAS) to colocate HIV prevention and clinical services at drug treatment clinics. In 1990, the initiative began funding drug treatment programs to provide HIV counseling, testing, and prevention services. HIV primary care was added the following year. Program implementation and development are described. An analysis is included of HIV counseling and testing data for the period 1990–2002 and quality of care data for five standardized quality measures with comparisons to data from other clinical settings. In the first 13 years of the initiative 168,340 HIV-antibody tests were conducted including 52,562 tests of injection drug users (IDUs) identifying 14,612 HIV-infected persons; the seroprevalence was 8.68%. By the end of 2000, the HIV primary care caseload peaked at 3,815 patients. Quality of primary medical care services among participating drug treatment programs has consistently matched or exceeded that provided in more conventional health care settings such as the hospitals and community health centers that were used as a basis for comparison. Colocating HIV primary care within substance use treatment is an effective strategy for providing accessible high-quality HIV prevention and primary care services. Rothman is with the Bureau of HIV Ambulatory Care, AIDS Institute, New York State Department of Health, Albany, New York, USA; Rudnick and Slifer are with the Substance Abuse Unit, AIDS Institute, New York, NY, USA; Agins is with the Office of the Medical Director, AIDS Institute, New York, NY, USA; Heiner is with the Karl Heiner Statistical Consulting, Ltd., Schenectady, New York, USA; Birkhead is with the AIDS Institute, Albany, New York, USA.     

Benefits of a rapid HIV test for evaluation of the source patient after occupational exposure of healthcare workers

Rapid human immunodeficiency virus (HIV) testing for the management of occupational exposure of healthcare workers significantly decreased the number of anti-retroviral post-exposure prophylaxis regimens started whilst awaiting HIV test results. The study confirmed an equivalent performance of the rapid test in comparison with HIV enzyme immunoassay, and suggests it is cost-effective. In addition, two other potential benefits emerged: reducing the number of source patients who remain untested and increasing the number of occupational exposures reported.     

Knowledge and attitudes of hospital staff to occupational exposure to bloodborne viruses

In order to assess awareness of occupational risk of exposure to bloodborne viruses a questionnaire was sent to 245 health care workers, representing a 10% sample of employees with patient contact in a large teaching hospital in Scotland, stratified by occupational group. One hundred and eight questionnaires (44%) were returned. Seventy per cent of respondents in laboratory and clinical areas described themselves as having sufficient knowledge for their own area of practice, but many gave incorrect answers or expressed uncertainty about the infectivity of HIV and hepatitis B and hepatitis C viruses. Ninety-four respondents were unaware that a regimen containing more than one antiretroviral drug is now recommended for post exposure prophylaxis of HIV infection, 37 thought they had been at risk of bloodborne viral infection and had contacted the occupational health department for advice, and 68 respondents disagreed with guidelines from the United Kingdom's General Medical Council on testing of patients for bloodborne viruses. The results indicate a need for educational initiatives for new and existing staff.     

HIV-related discrimination: a survey of New South Wales general practitioners

Abstract: This study aimed to investigate the correlates of human immunodeficiency virus (HlV)-related discrimination among general practitioners. The survey, conducted in 1993–1994, covered a random sample of 878 general practitioners from six of the 12 New South Wales health areas, augmented by 44 general practitioners from the same areas who were antiretroviral drug prescribers. The response rate was 51 per cent, and the final usable sample was 451. Variables examined were: demographic characteristics, the number of HIV-infected patients, personal contact with people living with HIV or AIDS, personal contact with homosexuals, the degree of anxiety about HIV or AIDS, and the degree of HIV-related discrimination. Discriminatory attitudes among general practitioners decreased as contact with HIV-infected patients (P < 0.001), other people living with HIV or AIDS (P< 0.001), and homosexuals (P < 0.001) increased. Anxiety about HIV or AIDS also decreased as contact increased (P < 0.001). Higher levels of anxiety were strongly associated with higher levels of HIV-related discrimination (P< 0.001). The demographic correlates of discrimination among general practitioners were the same as those found in the wider population. The professional care of people living with HIV and AIDS was concentrated among a small number of general practitioners, many of whom were homosexual. Ten general practitioners were carrying extraordinarily high caseloads of over 200 HIV-infected patients each. Older, heterosexual and male general practitioners are an important target for education campaigns, and the professional care of people living with HIV or AIDS should be encouraged among a wider group of general practitioners.     

Modelling HIV/AIDS epidemics in Botswana and India: impact of interventions to prevent transmission

OBJECTIVE: To describe a dynamic compartmental simulation model for Botswana and India, developed to identify the best strategies for preventing spread of HIV/AIDS. METHODS: The following interventions were considered: a behavioural intervention focused on female sex workers; a conventional programme for the treatment of sexually transmitted infections; a programme for the prevention of mother-to-child transmission; an antiretroviral treatment programme for the entire population, based on a single regimen; and an antiretroviral treatment programme for sex workers only, also based on a single regimen. FINDINGS: The interventions directed at sex workers as well as those dealing with sexually transmitted infections showed promise for long-term prevention of human immunodeficiency virus (HIV) infection, although their relative ranking was uncertain. In India, a sex worker intervention would drive the epidemic to extinction. In Botswana none of the interventions alone would achieve this, although the prevalence of HIV would be reduced by almost 50%. Mother-to-child transmission programmes could reduce HIV transmission to infants, but would have no impact on the epidemic itself. In the long run, interventions targeting sexual transmission would be even more effective in reducing the number of HIV-infected children than mother-to-child transmission programmes. Antiretroviral therapy would prevent transmission in the short term, but eventually its effects would wane because of the development of drug resistance. CONCLUSION: Depending on the country and how the antiretroviral therapy was targeted, 25-100% of HIV cases would be drug- resistant after 30 years of use.     

HIV/AIDS and blindness

Nearly 34 million people are currently living with HIV/AIDS: ocular complications are common, affecting 50% to 75% of all such patients at some point during the course of their illness. Cytomegalovirus retinitis is by far the most frequent cause of vision loss in patients with AIDS. Although the prevalence of cytomegalovirus retinitis is decreasing in industrialized countries because of the widespread availability of highly active antiretroviral therapy, between 10% and 20% of HIV-infected patients worldwide can be expected to lose vision in one or both eyes as a result of ocular cytomegalovirus infection. Less frequent but important causes of bilateral vision loss in patients with HIV/AIDS include varicella zoster virus and herpes simplex virus retinitis, HIV-related ischaemic microvasculopathy, ocular syphilis, ocular tuberculosis, cryptococcal meningitis, and ocular toxic or allergic drug reactions. At present, most patients with HIV/AIDS in developing countries who lose their vision have a very limited life expectancy. As antiretroviral therapy makes its way to these countries, however, both life expectancy and the prevalence of blindness related to HIV/AIDS can be expected to increase dramatically.     

Access to and use of HIV antiretroviral therapy: variation by race/ethnicity in two public insurance programs in the U.S

OBJECTIVES: To examine access to and use of HIV highly active antiretroviral therapy (HAART) by race/ethnicity in Medicaid and the AIDS Drug Assistance Program (ADAP) in 1998 in four states. METHODS: The authors analyzed reimbursement claims and AIDS surveillance data in California, Florida, New York, and Texas. Study subjects were identified using diagnostic or medication codes specific to HIV. The race/ethnicity of program enrollees was compared to representation in the HIV epidemic to examine access. Claims for antiretroviral (ARV) use were compared to U.S. Public Health Service treatment guidelines to assess HAART use. RESULTS: The authors identified 151,000 HIV-infected individuals in these two programs in the four states. Evidence of AIDS or symptomatic HIV was present in 78%-88% of enrollees in Medicaid, versus 31%-48% in ADAP. African Americans participated in Medicaid 10%-53% above and in ADAP 17%-31% below representation in the epidemic. Non-Latino whites exhibited the opposite pattern, being in Medicaid 5%-38% below and in ADAP 9%-65% above epidemic representation. Latinos participated more in ADAP (7%-31%), except in New York. HAART use over 90 days (July-September) ranged from 38% to 76% by program and state. Differences by race/ethnicity were inconsistent and small: African Americans had lower HAART use by 6%-14% in California and Florida Medicaid, and Latinos had higher HAART use by 2%-11% in ADAP and in Texas Medicaid. CONCLUSIONS: African Americans were more likely to access HIV drugs through Medicaid than through ADAP, which may reflect differences in program eligibility criteria as well as care seeking later in HIV disease. Differences in the use of HAART by race/ethnicity within state programs were small.     

Estimation of HIV Prevalence,Risk Factors,and Testing Frequency among Sexually Active Men Who Have Sex with Men,Aged 18–64 Years—New York City, 2002

Population-based estimates of human immunodeficiency virus (HIV) prevalence and risk behaviors among men who have sex with men (MSM) are valuable for HIV prevention planning but not widely available, especially at the local level. We combined two population-based data sources to estimate prevalence of diagnosed HIV infection, HIV-associated risk-behaviors, and HIV testing patterns among sexually active MSM in New York City (NYC). HIV/AIDS surveillance data were used to determine the number of living males reporting a history of sex with men who had been diagnosed in NYC with HIV infection through 2002 (23% of HIV-infected males did not have HIV transmission risk information available). Sexual behavior data from a cross-sectional telephone survey were used to estimate the number of sexually active MSM in NYC in 2002. Prevalence of diagnosed HIV infection was estimated using the ratio of HIV-infected MSM to sexually active MSM. The estimated base prevalence of diagnosed HIV infection was 8.4% overall (95% confidence interval [CI] = 7.5–9.6). Diagnosed HIV prevalence was highest among MSM who were non-Hispanic black (12.6%, 95% CI = 9.8–17.6), aged 35–44 (12.6%, 95% CI = 10.4–15.9), or 45–54 years (13.1%, 95% CI = 10.2–18.3), and residents of Manhattan (17.7%, 95% CI = 14.5–22.8). Overall, 37% (95% CI = 32–43%) of MSM reported using a condom at last sex, and 34% (95% CI = 28–39%) reported being tested for HIV in the past year. Estimates derived through sensitivity analyses (assigning a range of HIV-infected males with no reported risk information as MSM) yielded higher diagnosed HIV prevalence estimates (11.0–13.2%). Accounting for additional undiagnosed HIV-infected MSM yielded even higher prevalence estimates. The high prevalence of diagnosed HIV among sexually active MSM in NYC is likely due to a combination of high incidence over the course of the epidemic and prolonged survival in the era of highly active antiretroviral therapy. Despite high HIV prevalence in this population, condom use and HIV testing are low. Combining complementary population-based data sources can provide critical HIV-related information to guide prevention efforts. Individual counseling and education interventions should focus on increasing condom use and encouraging safer sex practices among all sexually active MSM, particularly those groups with low levels of condom use and multiple sex partners At the time this work was conducted, Manning and Marx were with the Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA, USA; Thorpe, Ramaswamy, Hajat, Marx, Karpati, Mostashari, and Pfeiffer are with the New York City Department of Health and Mental Hygiene, New York, NY, USA; Nash is with the Department of Epidemiology and International Center for AIDS Care and Treatment Programs, Columbia Mailman School of Public Health, New York, NY, USA; Manning is with the Massachusetts Department of Public Health, Bureau of Family and Community Health, Boston, MA, USA.     

Psychosocial characteristics of New York City HIV-infected women before and after the advent of HAART

OBJECTIVES: We compared level of psychosocial distress of HIV-infected women living in New York City before the advent of highly active antiretroviral therapy (HAART) with level of psychosocial distress reported by women living with the disease after the use of HAART became widespread. METHODS: Data were from HIV-positive New York City women aged 18 to 50 years, enrolled through outreach and self-referral. We compared scores on measures of psychological state and psychosocial adjustment to illness of 74 women interviewed in 1994-1996 with scores of a matched group of 74 women interviewed in 2000-2002. RESULTS: A significant difference between groups was found only with regard to adjustment to illness in their domestic environment, with poorer adjustment reported, on average, by women in the 2000-2002 sample. CONCLUSIONS: Although new treatments have significantly improved the physical health of those living with HIV/AIDS, no evidence was found that these treatments significantly improved psychological health for women, regardless of history of protease inhibitor use.     

Aging and HIV Infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research. Dr. Klein and Dr. Schoenbaun are with the Division of Infectious Diseases, Department of Medicine and The AIDS Research Program, Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Anastos is with the Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Minkoff is with the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY; Dr. Sacks is with the Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, NY.