Management of accidental exposure to HIV: the COREVIH 2011 activity report.

BACKGROUND: Post-exposure prophylaxis (PEP) relies on procedures allowing quick access to treatment in case of accidental exposure to viral risk (AEV). Occupational blood exposure (OBE) affects mainly caregivers; these accidents are monitored and assessed by the inter-regional center for nosocomial infections (C-CLIN), occupational physicians, and infection control units. They are classified apart from sexual exposure for which there is currently no monitoring. METHODS: Data was extracted from the COREVIH (steering committee for the prevention of HIV infection) 2011 activity reports (AR), available online. Data collection was performed using a standardized grid. RESULTS: Twenty-four out of 28 AR were available online. Nine thousand nine hundred and twenty AEV were reported, 44% of OBE, and 56% of sexual and other exposures. PEP was prescribed in 8% of OBE and in 77% of sexual exposures. The type of PEP was documented in 52% of the cases. Follow-up was poorly documented. CONCLUSION: AR provide an incomplete and heterogeneous review of exposure management without any standardized data collection. The difficulties encountered in data collection and monitoring are due to differences in care centers (complex patient circuits, multiple actors) and lack of common dedicated software. Sexual exposures account for 50% of AEV and most are treated; but they are incompletely reported and consequently not analyzed at the regional or national level. A typical AR collection grid is being studied in 2 COREVIH, with the objective to improve collection and obtain useful national data.

Factors associated with patient and health care system delay in the diagnosis of tuberculosis in France.

OBJECTIVE: To analyse diagnostic delay in tuberculosis (TB) patients. DESIGN: Cross-sectional study: all patients with TB notified to the French national surveillance system from April to June 2010 were interviewed face-to-face using a standardised questionnaire to assess symptom history and health-seeking trajectories. RESULTS: Of 225 patients enrolled, 172 (76.4%) had pulmonary TB, including 88 who were smear-positive. Mean delay between first symptoms and diagnosis (total delay) was 97 days (median 68, IQR 33-111), with a mean of 47 days (median 14, IQR 0-53) between first symptoms and health care contact (patient delay), and 48 days (median 25, IQR 6-67) between health care contact and diagnosis (health system delay). Factors independently associated with shortened total delay were medical insurance (OR 0.24, P = 0.014) and previous TB (OR 0.28, P = 0.049). Those associated with reduced patient delay were initial fever (OR 0.42, P = 0.03) and being followed by a general practitioner (OR 0.22, P = 0.004), while those associated with reduced health system delay were first health care contact within a hospital (OR 0.15, P < 0.001). Empirical antibiotic treatment was associated with increased health system delay (OR 4.4, P = 0.001). CONCLUSION: TB diagnostic delay needs to be reduced in France. This may be achieved through improved access to care, earlier hospital referral, and less use of empirical antibiotic treatment.

Cost-effectiveness of QuantiFERON-TB test vs. tuberculin skin test in the diagnosis of latent tuberculosis infection.

OBJECTIVE: To evaluate the cost-effectiveness of the tuberculin skin test (TST), the QuantiFERON-TB Gold test (QFT) and a combination of TST and QFT (TST+QFT) for diagnosing latent tuberculosis infection (LTBI) in France in a bacille Calmette-Guérin (BCG) vaccinated population. METHODS: A decision analysis model evaluated three strategies among simulated adults in close contact with tuberculosis (TB). We calculated direct lifetime medical costs, life expectancies and incremental cost-effectiveness ratios (ICERs). RESULTS: The discounted direct medical costs of care per patient of no testing, TST, QFT and TST+QFT were respectively euro417, euro476, euro443 and euro435, while discounted life expectancies were respectively 25.030, 25.071, 25.073 and 25.062 years. TST had higher costs and lower efficacy than QFT; TST+QFT was associated with an ICER of euro560 per year of life gained (YLG) compared to no testing, and QFT was associated with an ICER of euro730/YLG compared to TST+QFT. The only scenario where QFT was associated with an ICER of >euro75 000/YLG was when the prevalence of LTBI around TB was low (<5%) and TST specificity high (>90%). CONCLUSIONS: In France, for the diagnosis of LTBI after close contact with TB, the TST is more expensive and less effective than QFT. Although it is more expensive, QFT is more effective and cost-effective than TST+QFT under a wide range of realistic test performance scenarios.

Costs and cost-effectiveness of different follow-up schedules for detection of occupational hepatitis C virus infection.

OBJECTIVE: The purpose of this study was to compare the costs and cost-effectiveness (C/E) of early hepatitis C virus (HCV) RNA testing (alternative-US recommendations) after occupational exposure to HCV with existing follow-up strategies: (1) French, anti-HCV antibodies and alanine transaminase (ALT) activity at months 1, 3 and 6; (2) European, monthly ALT activity for 4 months and anti-HCV antibodies at month 6; (3) and baseline-US, anti-HCV antibodies and ALT activity at month 6. METHODS: A decision tree simulated each strategy for 7300 healthcare workers (HCWs) exposed to HCV each year in France, taking into account the impact of early diagnosis on the response to antiviral treatment and the deterioration of HCW quality of life after exposure. RESULTS: For a HCV transmission risk of 0.5% after exposure, the French strategy led to the highest costs/person (181.40 euros) and the baseline-US strategy to the lowest (126.60 euros) (178.50 euros) for alternative-US). The shortest mean time to HCV infection diagnosis (1 month) and the lowest number of chronic hepatitis C (CHC) patients (1.9/7300 HCWs exposed) was obtained with the alternative-US strategy (vs 6 months and 7.9 CHC, respectively with baseline-US). Compared with the alternative-US, the French strategy was associated with higher costs and lower utilities, and the European with a higher incremental C/E ratio. Compared with the baseline-US strategy, the alternative-US strategy C/E ratio was 2020 euros per quality-adjusted life year saved. CONCLUSION: In HCWs exposed to HCV, a strategy based on early HCV RNA testing shortens the period during which the HCW's wait for his HCV status, leads to lower risk of progression to CHC and is reasonably cost-effective.

Role of safety-engineered devices in preventing needlestick injuries in 32 French hospitals.

OBJECTIVES: To evaluate safety-engineered devices (SEDs) with respect to their effectiveness in preventing needlestick injuries (NSIs) in healthcare settings and their importance among other preventive measures. DESIGN: Multicenter prospective survey with a 1-year follow-up period during which all incident NSIs and their circumstances were reported. Data were prospectively collected during a 12-month period from April 1999 through March 2000. The procedures for which the risk of NSI was high were also reported 1 week per quarter to estimate procedure-specific NSI rates. Device types were documented. Because SEDs were not in use when a similar survey was conducted in 1990, their impact was also evaluated by comparing findings from the recent and previous surveys. SETTING: A total of 102 medical units from 32 hospitals in France. PARTICIPANTS: A total of 1,506 nurses in medical or intensive care units. RESULTS: A total of 110 NSIs occurring during at-risk procedures performed by nurses were documented. According to data from the 2000 survey, use of SEDs during phlebotomy procedures was associated with a 74% lower risk (P<.01). The mean NSI rate for all relevant nursing procedures was estimated to be 4.72 cases per 100,000 procedures, for a 75% decrease since 1990 (P<.01); however, the decrease in NSI rates varied considerably according to procedure type. Between 1990 and 2000, decreases in the NSI rates for each procedure were strongly correlated with increases in the frequency of SED use (r=0.88; P<.02). CONCLUSION: In this French hospital network, the use of SEDs was associated with a significantly lower NSI rate and was probably the most important preventive factor.

Assessment of right ventricle function and pulmonary artery circulation by cine-MRI in patients with AIDS.

OBJECTIVE: To evaluate right ventricle (RV) anatomy and performance and its relationships with pulmonary circulation in AIDS patients. DESIGN: We conducted a prospective blinded study by using cine-MRI, a well-accepted method to assess RV and pulmonary circulation. SETTING: A university hospital. PARTICIPANTS: Ten healthy volunteers and 13 asymptomatic AIDS patients. MEASUREMENTS: RV end-diastolic and end-systolic volumes, RV ejection fraction (RVEF), pulmonary artery (PA) diameter, main pulmonary artery distensibility (MPAD), RV free wall diastolic thickness (RVWT), and RV mass were measured. The RVWT/left ventricular wall thickness index was calculated. RESULTS: AIDS patients had significantly increased RV end-diastolic and end-systolic volumes and decreased RVEF (50 +/- 10 vs 59 +/- 6; p < 0.03). Four AIDS patients had RV wall motion abnormalities; 5 (38%) had an RVEF under 45%. RVWT, the RVWT/left ventricular wall thickness index, and PA diameter were significantly increased in AIDS patients. RV mass was increased in 54% of AIDS patients. MPAD was significantly lower in AIDS patients (18.8 +/- 15 vs 26 +/- 4; p < 0.01). A significant relationship was found between RV mass and MPAD (r = 0.76; p = 0.02). CONCLUSIONS: RV function is frequently impaired in AIDS patients. Anatomic and functional abnormalities found in RV and PA parameters suggest a systolic overload on RV. Pulmonary circulation abnormalities may influence RV structure and function in AIDS patients.

Resting energy expenditure in human immunodeficiency virus-infected patients: comparison between patients with and without secondary infections.

Resting energy expenditure (REE) was measured in 165 malnourished patients with human immunodeficiency virus infection and compared with that of 31 control subjects. Of these patients, 129 had no symptoms of secondary infections (NI), whereas 36 had evolving secondary infection (I) despite a body temperature < 38 degrees C. Mean REE was 11% higher in the NI group than in the control group (P < 0.05); it was 34% higher in the I group than in the control group (P < 0.001) and 21% higher than in the NI group (P < 0.01). In all cases the best predictive variable for REE was the fat-free mass (FFM) (r = 0.77, P < 0.001 in NI; r = 0.70, P < 0.001 in I; r = 0.78 in the control group. The REE-FFM ratio was 152.5 +/- 1.2 and 207 +/- 5.4 kJ.kg-1.d-1 in the NI and I groups, respectively. A high energy expenditure may be a harbinger of secondary infection in acquired immunodeficiency syndrome and may participate in accelerated weight loss.

Resting energy expenditure is increased in stable, malnourished HIV-infected patients.

Resting energy expenditure (REE) was measured by reference to body composition in 50 malnourished patients with human immunodeficiency virus (HIV) infection and compared with that of 14 healthy subjects. Among HIV patients, 40 had acquired immune deficiency syndrome (AIDS) and 10 had AIDS-related complex (ARC). All were in stable condition and had a previous history of progressive wasting, ie, a mean body weight loss of 14.2 +/- 8.1 kg over 16.6 mo (range 2-49 ms). The mean REE was 14% higher than estimated basal energy expenditure (EBEE), according to the Harris and Benedict formula. Thirty-four patients (68%) were classified as hypermetabolic (REE greater than 110% EBEE). The best predictable variable for REE was fat-free mass (FFM), as determined by an anthropometric method (r = 0.72; P less than 0.001). The mean REE was 12% higher in HIV patients than in the control group FFM (156 +/- 19 vs 124 +/- 17 kJ.kg FFM-1.d-1). We concluded that in stable and malnourished HIV patients, the progressive wasting may be partly related to an increase in REE. The mechanism of this hypermetabolic state remains to be established.