Self-start HIV postexposure prophylaxis (PEPSE), to reduce time to first dose and increase efficacy.

BACKGROUND: Effectiveness of HIV postexposure prophylaxis (PEPSE) correlates with speed of uptake following HIV exposure. Time to first dose has not improved in the UK for over 10 years. On-demand pre-exposure prophylaxis (PrEP) has shown that people can self-start medication for HIV prevention.We hypothesised that advanced provision of PEPSE (HOME PEPSE) for men who have sex with men (MSM) to self- initiate would reduce time to first dose following HIV exposure. METHODS: Phase IV, randomised, prospective, 48-week, open-label study was carried out. MSM at medium risk of acquiring HIV were randomised (1:1) to immediate or deferred standard of care (SOC) HOME PEPSE. Every 12 weeks, participants self-completed mental health/risk behaviour surveys and had HIV/sexually transmitted infection (STI) testing.HOME PEPSE comprised a 5-day pack of emtricitabine/tenofovir disoproxil fumarate/maraviroc 600 mg once daily initiated following potential exposure to HIV. If taken, participants completed a risk survey; PEPSE continuation was physician directed. Primary outcome was time from potential exposure to HIV to first PEPSE dose. FINDINGS: 139 participants randomised 1:1; 69 to immediate HOME PEPSE and 70 to deferred HOME PEPSE. Median age 30 years (IQR 26-39), 75% white, 55% UK born and 72% university educated. 31 in HOME PEPSE and 15 in SOC arm initiated PEPSE. Uptake of HOME PEPSE was appropriate in 27/31 cases (87%, 95% CI: 71% to 95%). Median time from exposure to first dose was 7.3 hours (3.0, 20.9) for HOME PEPSE and 28.5 hours (17.3, 34.0) for SOC (p<0.01). HOME PEPSE was well tolerated with no discontinuations.No significant differences in missed opportunities for PEPSE uptake, sexual behaviour or bacterial STI infections between treatment arms. INTERPRETATION: HOME PEPSE reduced the time from exposure to first-dose PEPSE by 21+ hours, with no impact on safety. This significantly improves the efficacy of PEPSE and provides an option for people declining PrEP.

Stepping up from opt-out: Achieving 100% uptake antenatal human immunodeficiency virus testing.

All pregnant women in the United Kingdom are offered and encouraged to take up screening for human immunodeficiency virus (HIV), hepatitis B and syphilis, with excellent uptake rates and engagement in care resulting in very few infants being infected with HIV in the United Kingdom. However, in that small number of women who decline testing, there remains an opportunity to offer further support to test and engage them and their baby in care, even if this happens in labour or immediately after birth. In addition, these women may be at increased risk of HIV. Our hospital is in an extremely high prevalence area for HIV, and most untested individuals are of childbearing age. We embarked on a quality improvement project to engage all women delivering at our unit in HIV testing or to test their babies via cord blood at birth. We sought to do this in a constructive and inclusive way, led by the HIV specialist midwife with the support of the HIV antenatal and the hospital senior management teams. Following an initial evaluation, the approach was modified and an innovative approach together with a trusted advocate was used to engage a particularly hard-to-reach group. We have achieved 100% uptake of HIV testing and made two HIV diagnoses that would not otherwise have been made; both in women who reported themselves not to be at risk and both engaged in care and delivered HIV-negative infants.

Preparing for PrEP; the cost of delaying universal access in England.

OBJECTIVES: Pre-exposure prophylaxis (PrEP) is not commissioned within National Health Service (NHS) England. Individuals can access it privately online or by enrolment into a clinical trial. We established a list of individuals not enrolled in trials, awaiting PrEP. In response to the observation that patients awaiting PrEP trials were being referred with newly diagnosed HIV, we aimed to measure attendance, incident HIV, STI acquisition and missed opportunities for prevention. METHODS: The search was conducted for patients on the list from November 2017 to November 2019. We examined the electronic clinical records of those on the list and extracted demographic information, STI and HIV diagnoses. In addition, for those diagnosed with HIV, we reviewed risk factors including chemsex and prior postexposure prophylaxis. RESULTS: There were 1073 patients on list, and 520 (48.6%) were still awaiting recruitment in a PrEP trial. Eight (0.75%) had an enrolment appointment booked while 200 (18.64%) had been contacted and deemed ineligible according to PrEP trial criteria. 45 (32.15%) had not responded to contact. We identified 15 new HIV infections in patients awaiting PrEP. Of these, 9/15 (60.00%) did not meet eligibility criteria at point of contact, though had been eligible at first referral. CONCLUSION: It is unacceptable that 15 patients acquired HIV while waiting. The individual lifetime cost of treating HIV is estimated at £360 800(1). This equals £5 412 000 for these 15 infections notwithstanding the psychological and physical burden. We advocate the immediate role out of universal PrEP for those who need it on the NHS. While this decision is delayed, harm is coming to those waiting. Wider provision of PrEP may encourage increased attendance, but must consider additional resources to accommodate added visits. We are relieved that at the point of final submission (21 March 2020) NHS England have recently announced funding of PrEP for eligible patients from, further details are pending.

Retrospective analysis of the associations and effectiveness of performing therapeutic drug monitoring in pregnant HIV-positive women in two large centres in Manchester.

There is no proven benefit for the routine use of therapeutic drug monitoring in HIV-positive pregnant women either for improving viral control or preventing mother-to-child transmission. This analysis reviewed a cohort of 171 HIV-positive pregnant women delivering between 1 January 2008 and 28 May 2013 to first establish which baseline characteristics are associated with having therapeutic drug monitoring performed, and whether therapeutic drug monitoring was associated with improved HIV control during pregnancy or mother-to-child transmission. Therapeutic drug monitoring was performed in 39% ( n = 66) of patients; it was associated with baseline characteristics of poor adherence to therapy (therapeutic drug monitoring 23% versus non-therapeutic drug monitoring 10%, p = 0.025) and the use of protease inhibitors (therapeutic drug monitoring 94% versus non-therapeutic drug monitoring 77%, p = 0.005). By multivariate analysis therapeutic drug monitoring was associated with medication alterations during pregnancy (therapeutic drug monitoring 68% versus non-therapeutic drug monitoring 12%, p = < 0.001), but not associated with any difference in viral load breakthrough during pregnancy (therapeutic drug monitoring 12% versus non-therapeutic drug monitoring 7%, p = 0.456) and viral load detectable at birth (therapeutic drug monitoring 14% versus non-therapeutic drug monitoring 9%, p = 0.503). There were no instances of mother-to-child transmission. Therapeutic drug monitoring's association with medication changes is postulated as partially causal in this cohort. There was no evidence of any association with improved control or reduced transmission of HIV to advocate routine therapeutic drug monitoring use.

The use of TDM in pregnant HIV-positive women: a retrospective cross-sectional review of five years practice in two large hospitals in Manchester.

INTRODUCTION: Despite plasma levels of certain HIV drugs decreasing in the third trimester of pregnancy there is no definitive evidence that therapeutic drug monitoring (TDM) improves HIV control and prevents mother-to-child transmission (MTCT). Indeed "one-off" TDM measurements are thought to poorly correlate with overall drug exposure [1]. We aim to describe baseline demographic and clinical characteristics of pregnant women with HIV, and to compare their HIV control, management during pregnancy and neonatal outcomes with respect to whether TDM was performed. MATERIALS AND METHODS: Retrospective cross-sectional case note analysis was performed on pregnant women with HIV who attended North Manchester General Hospital and Manchester Royal Infirmary from 1st January 2008 to 28th May 2013. RESULTS: A total of 171 pregnancies were included; 39% (n=66) had TDM. The majority of patients were of African origin (85%) and age range was 16-42 years (median 32 years). TDM was found to be associated with a history of poor adherence to therapy (TDM 23%, vs no TDM 10%, p=0.017), although baseline viral load (VL) and CD4 counts were comparable between TDM and non-TDM groups (p=0.4756 and 0.9492, respectively). TDM was also associated with protease inhibitors (PI) (TDM 94% vs no TDM 77%, p= 0.004). Within the PI group, TDM was more strongly associated with atazanavir use than other PI's (55%, p=0.023). TDM was not associated with any other demographic variable or with either of the two hospital sites (p=0.427). TDM was associated with medication alterations during pregnancy (TDM 67% vs no TDM 13%, p=0.052), but was not associated with any difference in outcomes with similar proportions of newly detectable VL during pregnancy (TDM 12% vs no TDM 7%, p=0.220) and VL detectable at birth (TDM 14% vs no TDM 9%, p= 0.293). There were no instances of MTCT. CONCLUSIONS: TDM was associated with PI use and a history of poor adherence at baseline. TDM was not associated with improved HIV control during pregnancy and there was no MTCT. TDM was not shown to have any additional benefit in pregnancy and its routine use is not recommended to improve HIV control or reduce MTCT.

Audit of the management of antiretroviral treatment-naïve HIV patients in Greater Manchester, UK.

We evaluated the management of antiretroviral treatment (ART)-naïve HIV-positive patients in Greater Manchester against the 2005 British HIV association (BHIVA) guidelines. Fifty-seven HIV patients (median age 36 years, 61% males, 53% black Africans) commenced their first ART regimen between 1 October and 31 December 2005. Most of them presented with advanced HIV disease (74% had CD4 lymphocytes <200 and 33% were Centers for Disease Control and Prevention stage C) and 51% commenced ART within three months of their HIV diagnosis. Ninety-six percent had baseline laboratory investigations performed but only 53% had baseline blood pressure estimation. Only 25% had urinalysis performed. A combination of two nucleoside reverse transcriptase inhibitors (NRTI) and one non-NRTI was chosen in 76% of patients. Eighty-two percent of patients had a clinical review and blood tests within five weeks of starting treatment.