[The post-exposure prophylaxis in all its forms]. / La prophylaxie postexposition dans tous ses états.

Every day physicians are confronted with situations that require evaluation concerning the indication for a post-exposition prophylaxis (PEP) for HIV or, less frequently, for hepatitis B (HBV). There is no specific prophylaxis for hepatitis C (HCV). In light of the experience gained in the domain of HIV in the last years, some international guidelines for PEP have been changed with regard to the choice of drugs and when to start PEP. This article attempts to resume the different factors contributing to the evaluation of PEP according to the local guidelines and to introduce the foreseen changes in the new Swiss-guidelines for PEP that will be released in autumn 2013.

Clinical relevance of cytomegalovirus viraemia(*,†).

BACKGROUND: Using new sensitive quantitative polymerase chain reaction (PCR) assays, cytomegalovirus (CMV) DNA is often detectable in the plasma of immunosuppressed patients. We investigated the prognostic value of a positive CMV DNA test for the development of CMV end-organ disease, other AIDS-defining events and mortality. METHODS: A survival analysis was performed, using the Kaplan-Meier method and Cox proportional hazards models, for patients prospectively followed in the Swiss HIV Cohort Study, from January 1996 to December 2007, who were CMV-seropositive, had a CD4 count of ≤ 100 cells/µL, and had a plasma sample available for the measurement of baseline CMV DNA with an ultrasensitive PCR. The outcome analysed was an AIDS-defining event, including CMV end-organ disease, or death. Variables analysed at the time of CMV measurement were demographic variables, CD4 cell counts, HIV-1 RNA loads, and use and type of highly active antiretroviral therapy (HAART). RESULTS: Of 1128 patients, 208 (18%) presented an AIDS-defining event and 246 (22%) died. A total of 368 patients (34% of samples) had detectable CMV DNA at baseline, with DNA concentrations of up to 38 800 copies/mL. In the multivariate analysis, CMV DNA predicted evolution not only towards CMV end-organ disease [hazard ratio (HR) 12.6; 95% confidence interval (CI) 4.27-37.41], but also towards other AIDS-defining events (HR 2.6; 95% CI 1.60-4.33) and death (HR 1.9; 95% CI 1.10-3.34). CONCLUSION: Quantitative CMV DNA detected in the plasma of HIV-infected patients with CD4 counts ≤ 100 cells/µL is a predictor for HIV disease progression, CMV disease and death. A single low value of 80 copies/mL identifies patients at low but significantly increased risk during the following months, after the measurement.

[PEP or no PEP? The rational of initiating postexposure prophylaxis]. / PEP ou pas PEP? Du rationnel de l'emploi des prophylaxies postexpositionnelles.

Every day, doctors are faced with the dilemma of starting a postexposure prophylaxis (PEP) against HIV, HBV and HCV. A 28 days course of highly active antiretroviral therapy, chosen on the basis of the source's HIV resistance profile, should be initiated, as soon as possible, to reduce the likelihood of HIV transmission. Complete vaccination against HBV (3 doses) is associated with a 100% seroprotection in children and 95% in adults. There is no specific prophylaxis against HCV. Because of the complexity of these situations, we have edited local guidelines, which take into account not only international and Swiss recommendations, but also our experts' opinions. It is important to stress that PEP does not replace standard precautions.