ABSTRACT
BACKGROUND: Post-exposure prophylaxis (PEP) for human immunodeficiency virus (HIV) is recommended to start within hours of needlestick injuries (NSIs) among healthcare workers (HCWs). Delays associated with awaiting the results of testing from the source patient (whose blood was involved in the NSI) can lead to psychological consequences for the exposed HCW as well as symptomatic toxicities from empiric PEP. AIMS: After developing a 'stat' (immediate) workflow that prioritized phlebotomy and resulting of source patient bloodwork for immediate handling and processing, we retrospectively investigated whether our new workflow had (i) decreased HIV order-result interval times for source patient HIV bloodwork and (ii) decreased the frequency of HIV PEP prescriptions being dispensed to exposed HCWs. METHODS: We retrospectively analysed NSI records to identify source patient HIV order-result intervals and PEP dispensing frequencies across a 6-year period (encompassing a 54-month pre-intervention period and 16-month post-intervention period). RESULTS: We identified 251 NSIs, which occurred at similar frequencies before versus after our intervention (means 3.54 NSIs and 3.75 NSIs per month, respectively). Median HIV order-result intervals decreased significantly (P < 0.05) from 195 to 156 min after our intervention, while the proportion of HCWs who received one or more doses of PEP decreased significantly (P < 0.001) from 50% (96/191) to 23% (14/60). CONCLUSION: Using a 'stat' workflow to prioritize source patient testing after NSIs, we achieved a modest decrease in order-result intervals and a dramatic decrease in HIV PEP dispensing rates. This simple intervention may improve HCWs' physical and psychological health during a traumatic time.
Subject(s)
HIV Infections , Needlestick Injuries , Occupational Exposure , HIV Infections/prevention & control , Health Personnel , Humans , Needlestick Injuries/prevention & control , Post-Exposure Prophylaxis , Retrospective Studies , WorkflowABSTRACT
As a consequence of inhibition of the hepatic cytochrome P450 3A4 isozyme, treatment with HIV protease inhibitors can result in significant drug-drug interactions. One noteworthy interaction is between protease inhibitors and inhaled or intranasal corticosteroids. This interaction can result in adrenal insufficiency and iatrogenic Cushing's syndrome (with symptoms such as rapid weight gain, obesity, facial hirsutism and swelling), as well as hypertension, osteoporosis and decreased CD4 cell count. In this paper, we review and unite pharmacokinetic data, case reports and current research regarding this drug-drug interaction in order to suggest options for the clinical management of HIV-positive patients requiring treatment with protease inhibitors and inhaled or intranasal corticosteroids.
Subject(s)
Adrenal Cortex Hormones/pharmacokinetics , HIV Protease Inhibitors/therapeutic use , HIV Seropositivity/drug therapy , Administration, Inhalation , Administration, Intranasal , Adolescent , Adrenal Cortex Hormones/administration & dosage , Adrenal Cortex Hormones/adverse effects , Adult , Aged , Anti-Inflammatory Agents/pharmacokinetics , Beclomethasone/administration & dosage , Beclomethasone/adverse effects , Beclomethasone/pharmacokinetics , Child , Child, Preschool , Cushing Syndrome/chemically induced , Cushing Syndrome/drug therapy , Drug Interactions , Female , Fluocinolone Acetonide/administration & dosage , Fluocinolone Acetonide/adverse effects , Fluocinolone Acetonide/analogs & derivatives , Fluocinolone Acetonide/pharmacokinetics , HIV Protease Inhibitors/administration & dosage , HIV Protease Inhibitors/adverse effects , Humans , Infant , Male , Middle Aged , Ritonavir/administration & dosage , Ritonavir/adverse effects , Ritonavir/pharmacokinetics , Young AdultABSTRACT
The objective of this study was to determine if a lower rate of adherence (<95%) is sufficient to maintain HIV viral suppression in patients on an efavirenz-based regimen. This study was a retrospective review of pharmacy refill records at an HIV specialty pharmacy at Montefiore Medical Center's outpatient clinic. Data from 151 HIV-positive patients on an efavirenz-based regimen with at least one undetectable viral load (HIV RNA < 400 copies/mL) from December 2003 through March 2005 were reviewed. Adherence was calculated based on the formula: [(pills dispensed/pills prescribed per day/days between refills)x100%]. Calculated adherence for each time-period was correlated to the respective HIV-RNA value for that period. Of 151 patients, viral suppression was maintained in greater than 80% of time periods for adherence rates as low as 85-90%. The periods with 75-80% adherence also had higher than 85% suppression. Rates of suppression began to fall when adherence decreased to < 75%. In conclusion, lower adherence rates (<95%) on an efavirenz-based regimen were more successful in maintaining viral suppression than previously found with unboosted protease inhibitor-based regimens.