ABSTRACT
Stringent eligibility criteria, drug costs and antiretroviral toxicities are challenges in delivering HIV non-occupational post-exposure prophylaxis (nPEP). We reviewed patients' nPEP eligibility and clinical outcomes at St Michael's Hospital, Toronto, Canada to identify opportunities for improvement. Of 241 patients, 59%, 36% and 6% presented for high- (receptive anal/vaginal, blood), medium- (insertive anal/vaginal) and low-risk (oral) sexual exposures, respectively, and nearly all (93%) presented within 72 hours. Of 205 patients given nPEP, 20 were known to have discontinued nPEP prematurely: three due to costs but none due to toxicities. Two HIV seroconversions occurred in patients with suspected ongoing potential exposures. Five asymptomatic syphilis diagnoses were made among 71 tested. Only 39% and 19% of nPEP patients returned to our institution for follow-up at 3-4 and six months, respectively. Our findings underscore the feasibility and importance of nPEP programmes to HIV and sexually transmitted infection control, while identifying opportunities for improvement.
Subject(s)
Anti-HIV Agents/administration & dosage , Eligibility Determination , HIV Infections/prevention & control , Outcome Assessment, Health Care , Post-Exposure Prophylaxis , Adult , Anti-HIV Agents/adverse effects , Canada , Drug Administration Schedule , Drug Therapy, Combination , Female , Follow-Up Studies , Humans , Male , Patient Compliance , Program Evaluation , Referral and Consultation , Retrospective Studies , Risk , Time FactorsABSTRACT
OBJECTIVES: Despite the recent publication of case reports describing various manifestations of tenofovir-related nephrotoxicity, data regarding the incidence of and risk factors for this adverse effect are currently lacking. METHODS: A retrospective cohort study of patients from four centres in Toronto, Canada, enrolled in the tenofovir expanded access programme with a minimum of 3 months follow up, was carried out. RESULTS: A total of 172 patients receiving tenofovir disoproxil fumarate (TDF) for a median of 16 months (range 3-25 months) were included in the study. Seven (4%) patients developed grade 1 (>44 micromol/L from baseline) increases in serum creatinine (SCr) during follow up; no patient developed grade 2 or higher nephrotoxicity. Fifteen (8.7%) patients had an increase in SCr of greater than 1.5 times baseline values during follow up. Four (2.3%) patients discontinued TDF because of an increase in SCr and/or abnormal urinalysis. Of 62 patients with a urinalysis, grade 1 or higher proteinuria (< 3 g/L) was observed in 27 (43%) patients. Only baseline SCr [odds ratio (OR)=0.51 per 10 micromol/L increase; P=0.0005] and baseline creatinine clearance (1.26 per 10 mL/min increase; P=0.01) were significantly associated with ever having a 1.5-fold increase in serum creatinine. Twenty-eight (16%) and 11 (6%) patients developed grade 1 (serum phosphorus < or = 0.71 mmol/L) and grade 2 (serum phosphorus < or = 0.61 mmol/L) hypophosphataemia during follow-up, respectively. CONCLUSIONS: Although slight increases in SCr did occur after starting TDF, clinically significant nephrotoxicity was rare. The clinical significance of TDF-related hypophosphataemia and proteinuria requires further study.
