This study allowed us to note the proportions of professional and non-professional AEB among all the patients consulting for AEB in the day care unit, to describe the different circumstances of AEB, to describe the attitudes of patients towards AEB and to specify the therapeutic options for hospital care over the years.
Over a 10-year period, we identified 600 female victims of AEB (426/600; 71%) with a sex ratio of 0.4. This predominance of women has been noted by other African authors [7–9]. This could be explained by a high proportion of women among the medical staff on the one hand and the higher frequency of rapes among women than among men on the other hand [10]. However, Ehui et al. in his Ivorian series of 2007 noted a male predominance (sex ratio M / F of 1.4) among the victims of AEB [11]. This difference could be linked to a fluctuation in sampling since 3 years later, the same author finds rather a female predominance (sex-ratio M / F of 0.6) as in most series of the literature [10].
The average age in our series was 30 ± 9.7 years with extremes of 11 and 67 years. These results are comparable to those of Ehui et al. in Ivory Coast and Gounongbé et al. in Benin who respectively noted the average ages of 33.8 ± 7.4 years [11] and 35.7 ± 8.8 years [8] in their studies.
The recommended consultation period for initiating post-exposure prophylaxis is 48 hours [3,4]. In our series 89% of individuals consulted within 48 hours of the onset of AEB. The Tunisian, Ivorian and French studies report proportions of consultations within less than 48 hours respectively of 89.8% [9], 93.7% [10] and 93% [1]. Most patients who suffered from AEB in our study, as in these Tunisian, Ivorian and French series, consulted within less than 48 hours; this demonstrates patient awareness and interest in reducing the risk of post-exposure infection. However, the proportion of our consulting patients less than 24 hours after exposure in our study was 66.7%. This proportion is lower than that the one of Hajjaji et al. who noted a proportion of 81.3% [9]. This difference could be due to the difference in our study populations; our study covered all the patients received for AEB including personnel health care and the general population while that of Hajjaji et al. was made up of trainee doctors; a homogeneous study population with a priori a level of medical knowledge superior to ours.
Among AEB in the health personnel, injections by syringe were the most represented 47.8% (141/295). Needlestick injuries remain the leading cause of professional AEB worldwide. This proportion of professional AEB due to needle sticks was 83% in 2007 in Ivory Coast [11], 85% in Tunisia in 2010 [9], 68% in Togo in 2011 [12]. Practices such as recapping needles, dragging needles in garbage bags could explain this high frequency of needlestick bites [11]. This would also require the establishment of communication programs for behavior change at national or even international level. As for non-professional AEB, rape was at the top of the line with a frequency of 36.7% compared to all AEB. Our results are similar to those of Rouveix et al. in France which reports a prevalence of AEB by sexual exposure of 31% [2]. In our series, as far as non-professional AEB is concerned, rape constitutes 72.1% (220/305), condom breaks 15.1% (46/305) and unprotected sex 10.2% (31/305). These data can be superimposed on those of Ehui et al. in 2010 which found 57.8% (74/128) of rapes, 22.6% (29/128) of condom breakage and 16.4% (21/128) of unprotected sex regarding non-professionals AEB in Abidjan [10].
Cleaning with soap (46.7%) and disinfection with bleach (19.3%) were the main measures taken by our patients after an AEB. Zougrana et al. in Burkina Faso in 2014 noted a similar frequency (30/64; 46.8%) of people victims of AEB who cleaned the site of exposure with water and soap [13]. Contrarily to Moroccan series where the frequency of this gesture was 68% [14]. In addition, in this same Moroccan series, almost all participants (97%) did hand disinfection after AEB, and in 83% of cases the disinfectant was with bleach [14]. Among our participants, disinfection concerned 86.5% of cases and was done with bleach in 26.5% of cases. This disparity could be explained by a poor level of mastery of precautionary measures among our participants compared to that of Asseray et al. who rather had a high level of control over precautionary measures [14]. Indeed, our study population was heterogeneous and included both the medical staff and the general population, while the Moroccan study consisted only of medical staff.
In our study, 44% of our source patients were HIV positive. Our results are comparable to those found in several African works. Indeed for Ehui et al. [11] in Ivory Coast and Beghdadli et al. [15] in Algeria these proportions were 46.7% and 51.7% respectively. In contrast, Gounongbé et al. in Benin had found a much lower proportion (10.2%). During our work, the patients consulted were mixed and almost proportional (49.2% of health personnel and 50.2% of the general population); due to the presence of half of the source patients in the hospital, performing the test in these patients was easier. Gounongbé et al. in Benin noted a high proportion of non-professional exposure (80%); and the serology of the majority of these non-professional AEB source patients was unknown probably because these non-professional AEB source patients were not in a hospital setting [8]. This situation must have reduced the proportion of source HIV positive patients (10.2%) in their study. Almost all of the consultant patients (97.5%) in our study had their HIV serology. Darouiche et al. reported that all patients with BSE have been tested in their series. This high rate of screening of source patients is favored by the accessibility or even the free testing for HIV testing set up by the health policies of the different states [16].
The prescription of post-exposure prophylaxis is variable in the literature and depends on the risk of contamination which can be minimal, low or high [3]. If the consultation is done within 48 hours, the prescription of a prophylaxis can be discussed depending on the level of risk and the type of exposure. Thus, in our study where we generally had a high risk of contamination increased by a high proportion of AEB through sexual penetration (297/600; 49.5%); the frequency of post-exposure prophylaxis was 94.2% (565/600). In the cohort of children from Monpoux et al. in France only 18.8% (6/48 AEB by sexual penetration, 3 by other means of AEB estimated to be high risk) received post-exposure prophylaxis [1]. The post-exposure prophylaxis prescribed for our patients was triple antiretroviral therapy. It is the most recommended and currently prescribed protocol, as shown by several studies [2,10,13]. Other therapies, in particular monotherapy with zidovudine and dual therapies combining zidovudine, remain alternatives [3]. Indeed, zidovudine is the first molecule whose efficacy has been proven in prophylaxis after exposure to HIV, in particular during the CDC control case study in 1995, with a notable reduction in seroconversion by 80% [3]. However, due to the development of resistance to zidovudine, it should no longer be prescribed alone [3]. Overall, new prophylaxis protocols recommend the association of two nucleoside reverse transcriptase inhibitors and one protease inhibitor.
Limits of the study:
The main difficulties encountered during our study were the absence in certain files of some information such as profession, precision of AEB circumstances. Almost all the files had no follow-up information; which did not allow us to have information on compliance and the proportion of post-exposure seroconversion.