AIDS post-exposure treatment for HIV prescribed excessive in France

Prophylaxis after potential exposure to HIV is prescribed excessively, many clinicians believe contacted by Reuters Health.

Also in emergency services

The recommendations for treatment of HIV infection recommend administering to people potentially exposed to the virus triple therapy for a period of 28 days, accompanied by a virological monitoring of up to four months.

However, a study by the Institute for Public Health Surveillance (VS), published in Aids, indicates that post-exposure treatment (TPE) as practiced in France, presents a cost-effective generally unfavorable. However, the results vary depending on the patient, the nature of the risk and the person causing potential infection.

According to this study, only 15.7% of the interventions are cost-effective, with less than $ 50,000 reports (or 39,020 euros) for each year of life gained quality-adjusted life year (QALY in English, for "quality-adjusted life year ").

These were mostly related to situations in which the source person is HIV positive (receptive anal intercourse, sharing needles, occupational exposure to blood), but also concern the case of homosexuals who have had receptive anal intercourse with a person unknown HIV status.

Few, however, interventions that prove cost-effective when they are the result of heterosexual relationships. Some may approach 60 million per QALY, especially in the most common cases (17.24% depending on the study) of men engaged in vaginal intercourse with women they do not know the HIV status.

Contacted by Reuters Health, Dr. Willy Rozenbaum, infectious disease specialist at St. Louis (AP-HP, Paris) hospital admits "just amazed" the findings of the InVS. The TPE "is a huge device whose benefits are far from clear," he believes.

Highlighting the risk of serious adverse effects of these treatments and the lack of certainty as to their effectiveness, the President of the National AIDS Council (NAC) is concerned that in the vast majority of cases, any person presenting to the emergency department receives TPE.

"We are in a precautionary principle that we prefer to intervene even if it is completely useless, rather than do nothing and something happens," he laments.

A study published by InVS, after which the authors also concluded overprescribed, seems to go in the same direction. Conducted in the region Provence-Alpes-Côte d'Azur (PACA), it indicates that 82% of consultations are concluded by prescribing antiretrovirals, in most cases by HAART.

However, "most doctors are experienced, they require less" TPE considers Dr. Rozenbaum.

The device being provided for patients who, because of non-working hours are addressed most frequently in emergency and consult within 48 hours to 96 hours after exposure an infectious disease responsible for reviewing the merits of TPE . Willy Rozenbaum said that for his part he "often stop treatment" at that time, while recognizing the importance of work experience in this field.

Of "a little more restricitives" recommendations

Treatment recommendations ("Yeni Report"), however, are "a little more restrictive than the previous recommendations," including cases of fellatio, for its part considers Prof. Elisabeth Bouvet, infectious disease specialist at the Bichat Hospital (AP-HP, Paris) and head of the working group on the prophylactic treatment during the preparation of the report.

Thus the recommendations indicate that the treatment is "talking" about whether the source is either HIV positive or of unknown HIV status but belonging to a group with a high prevalence of infection (homosexual, bisexual, injecting drug users ). In both cases, this discussion should be based on the presence of aggravating factors such as high viral load or genital lesions.

But according to a report, though it generalizes the TPE if the partner is HIV positive, do not see the point of treatment if HIV status is unknown. Nevertheless, the study shows that the requirements InVS secondary TPE fellatio, cost-effective very unfavorable concern only 4.75% of cases.

As Willy Rozenbaum, Elisabeth Bouvet believes that knowledge of the status of the partner is one of the crucial points of the decision. "Everything must be done so that the partner be tested," she believes, noting the physician's role in this process.

She says there is "a message to spend more in homosexuals." The study reveals InVS, in fact, that the treatment is particularly cost-effective for them, especially in situations of receptive anal intercourse with a partner of unknown HIV status.

A refusal requirement "ethically intolerable"

The Deputy Director General of Aides, Vincent Pelletier, also recognizes that "the people who come are not necessarily the most vulnerable." "Better to target the most likely to benefit from a post-exposure treatment populations," he says.

As for the possible over-prescription, he understands the difficulty of the doctor to "respond to a distress", but a judge refused to administer a TPE is "ethically intolerable."

Dr. Frédérique Delatour, the Directorate General of Health (DGS) and worked in the working group Elisabeth Bouvet in the development of Yeni report, informs Reuters Health in developing a circular on TPE, which "will disseminate the recommendations of the expert report in 2006" and address the issue of low-risk situations transmission.