Harmonised European recommendations for the management
of HIV exposure have been needed for some time. Important and impressive
work has been achieved by two groups of experts from a total of 14 countries,
and their conclusions and recommendations are reported in the two papers
from Jesús Almeda et al and Vincenzo Puro et al [1,2].
Two characteristic settings are specified, although the difference between
each is debatable if the issue is to avoid or prevent an established infection
after exposure to HIV (or, indeed, HCV or HBV). As the authors point out,
post-exposure prophylaxis (PEP) is the standard of care for healthcare
workers (HCW) in almost all countries including the United States, but
not for the management of sexual, injecting drug use or other non-occupational
exposures to HIV.
In the case of HCW occupational exposure, the authors' task was to standardise
several national recommendations and strategies. For non-occupational
exposure, the aim was to establish European guidelines, as very few national
recommendations exist.
As these articles show, the rationale, background, management, and choice
of treatment for PEP are very similar in both situations.
It is very important for healthcare workers to know that their institution
has guidelines to protect them from occupational risks. In such situations,
the source patient is usually accessible for rapid testing, which helps
with risk evaluation and the therapeutic decision. Healthcare workers
can also seek information and care on site immediately following exposure,
which is very important for the outcome of the post-exposure care.
In cases of sexual exposure, access to the physician, and the physician's
decision are more difficult and will take longer, since the source patient
is often unknown or unavailable for testing. Moreover, the outcome (HIV
status at 6 months) is frequently not properly assessed because patients
are lost to follow up.
Despite these major differences, both type of exposure deserve the same
multidisciplinary and comprehensive network of specialists for post-exposure
care. Because the efficacy of PEP is linked to the delay of therapy initiation,
it is important for medical teams and institutions to consider risk assessment
as an emergency and to provide a ready accessibility to evaluation and
PEP 24 hours a day. In our experience, sexually exposed patients frequently
seek advice or care at night or at weekends, which are not the best times
for a full assessment of the situation; in these cases we recommend starting
PEP as soon as possible after counselling, with reassessment of the patient
by a specialist the following morning so that the PEP indication can be
reconsidered. It is preferable to stop antiretroviral treatment after
one or two days than to realise that it is too late to start it if indicated.
Informing healthcare workers and the general public about the limitations
of PEP: four weeks of therapy with potential side effects and toxicity,
and a follow up with medical visits and blood test. PEP cannot be used
as a 'morning after pill', as is sometimes requested by patients after
risky sexual behaviour. On the other hand, it is important to know that
PEP can be recommended for rape victims and should be available in these
situations. For medical teams or physicians, these recommendations will
help in giving adequate counselling and care or in referring the person
to a specialist unit after a first evaluation. However, post-exposure
care is time consuming for the specialist team, as it is not only the
initial assessment and prescription that will contribute to the success
of the PEP. Monitoring adherence to therapy, clinical tolerance and toxicity,
psychological impact, and organising scheduled visits and testing are
all mandatory for the success of the care. Recommendations on the choice
of drugs will have to be updated regularly, as knowledge is moving quickly
in the field of antiretroviral therapy. The most important point is that
PEP is not indicated for an infected or sick person and that the risk-benefit
ratio is therefore of major importance. In our institution we consider
the assessment and the decision whether of not to treat to be the most
important part of post-exposure care. The drugs have to reach the HIV
target cells for replication before effective integration of the HIV genome,
which is why the time elapsed between exposure and initiation of treatment
is so important.
As the authors mention, a triple combination with two nucleoside analogues
and a protease inhibitor are a good choice in terms of efficacy. We would
also take the number of pills and the number of doses per day into consideration,
as compliance is essential. In terms of risk and tolerance, we would not
recommend nevirapine or abacavir (as recommended here) because of early
toxicities such as hypersensitivity or hepatitis, but we do not use efavirenz
either because of the dizziness and sleeping problems that may occur during
the first days of therapy, and which would compromise the therapy in these
anxious patients.
Finally, we will all benefit from these European recommendations which
are both well documented and very informative. Little is known about the
impact of NONOPEP on behaviour, or its efficacy, and so I would strongly
support the idea, mentioned in the conclusion, of the need for a prospective
evaluation of its use in the European countries.
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