Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Abstract

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

The public health impact of widespread availability of nonoccupational postexposure prophylaxis against HIV

“…For male-to-male sex, the prevalence of HIV infection among gay men was based on self-reported HIV status as recorded in Australian community-based cross-sectional studies in 2003-2005 [17-20]. These estimates were 5.1% in Canberra,6.4% in Brisbane, 9.1% in Melbourne and 14.2% in Sydney. Average seroprevalence weighted for state of residence was calculated.…”

“…Only a relatively small number of countries have published guidelines recommending its use [1][2][3][4][5]. Available guidelines are inconsistent with respect to the recommended antiretroviral regimen, including the choice of two vs. three drugs, the type of exposures that are eligible, and whether or not the source is required to be HIV positive [6,7].…”

“…Only a relatively small number of countries have published guidelines recommending its use [1][2][3][4][5]. Available guidelines are inconsistent with respect to the recommended antiretroviral regimen, including the choice of two vs. three drugs, the type of exposures that are eligible, and whether or not the source is required to be HIV positive [6,7].Implementation of NPEP on a more extensive scale has been impeded by concerns about its efficacy, inappropriate use, toxicities and potential undermining of behavioural HIV infection prevention strategies [8][9][10].In Australia, guidelines recommending the use of NPEP after high-risk exposures were released in New South Wales (NSW) in 1998 [4], and national guidelines were published in 2001 [11]. The guidelines have been widely promoted among doctors and among people at high risk of HIV infection, predominantly homosexual men.…”

Will I? Won't I? Why do men who have sex with men present for post-exposure prophylaxis for sexual exposures?

“…However, there have been numerous reports of seroconversion following PEPSE,13 – 15 17 – 19 which has been largely attributed to ongoing risk behaviour and subsequent viral exposure.…”

HIV Antiretroviral Postexposure Prophylaxis: A Cautionary Note

“…These guidelines all recommend the earliest possible initiation of therapy (within 72 h after exposure) with multiple drugs for 28 days [18][19][20][21][22][23][24][25][26].…”