PEP for HIV Prevention 3...There is a significant debate on the need to use PEP after exposure. The...
Transcript of PEP for HIV Prevention 3...There is a significant debate on the need to use PEP after exposure. The...
PEP for HIV Prevention Mostafa El Nakib MD,MPH
N.A.P
WHAT is PEP
Post- exposure prophylaxis (PEP) is a short-term antiretroviral treatment to reduce
the likelihood of HIV infection after potential exposure to the virus either:
1. Occupationally (accidental exposure to the virus)
2. Trough sexual intercourse
Within the health sector , PEP should be provided as part of a comprehensive
universal precautions package that reduces staff exposure to infectious hazards at
work
Why it is important
The risk of transmission of HIV from an infected patient through a needle stick where
the skin is punctured by a sharp is less than 1%
The risk of transmission from exposure to infected fluids or tissues is believed to be
lower than for exposure to infected blood
The risk of exposure from needle sticks and other means exists in many settings
where protective supplies are limited and the rates of HIV infection in the patient
population are high
The availability of PEP may reduce the occurrence of occupationally acquired HIV
infection in health care workers
It is believed that the availability of PEP for health workers will serve to increase staff
motivation to work with people infected with HIV and may help to retain staff
concerned about the risk of exposure to HIV in the workplace
There is a significant debate on the need to use PEP after exposure.
The MOPH offers PEP for free for the occupational exposure and
rape cases only
The UN offers PEP to its staff in cases of rape and when the
likelihood of HIV exposure is considered high ,special high risk
behaviors are included as well
Prevention of exposure
Prevention of exposure to the HIV remains the most
effective measure to reduce the risk of viral transmission to
health workers:
By applying the prevention methods (universal
precautions) .
By providing them with the necessary materials
and protective equipment .
Managing occupational exposure to HIV
First aid should be given immediately after the injury : wounds and skin sites exposed to blood or body fluids should be washed with soap and water , and mucous membranes flushed with water
The exposure should be evaluated for potential to transmit HIV infection ( based on body substance and severity of exposure)
The exposure source should be evaluated for HIV infection. testing of source persons should only occur after obtaining informed consent, and should include appropriate counseling and care referral. Confidentiality must be maintained
Clinical evaluation and baseline testing of the exposed health care worker should proceed only after informed consent
Exposure risk reduction education should occur with counselors reviewing the sequence of events that proceeded the exposure in a sensitive and non-judgmental way.
GUIDELINES FOR POST-EXPOSURE PROPHYLAXIS (PEP)
The implementation of standard infection control
practices should avert the risks of exposure to
potential risks of acquiring blood borne pathogens
including HIV.
An exposure is considered risky when occurring through percutaneous injury 1. a needle
2. cut with a sharp object
Also:
1. contact of mucous membrane
2. non intact skin with blood, tissue, other body fluids that are potentially
infectious
The following body secretions are considered potentially infectious: Blood
visibly bloody body fluids
semen and vaginal secretions
cerebrospinal fluid
synovial fluid
pleural fluid
peritoneal fluid
pericardial fluid
Amniotic fluid
The following body secretions are not considered potentially infectious unless they are visibly bloody:
Feces nasal secretions
saliva
Sputum sweat
tears
urine
vomitus
The average risk of transmission via a percutaneous route has been estimated at
approximately 0.3%
The risk from biological fluids other than blood is less.
Exposure of non intact skin is estimated to be much less and even
lower than exposure through mucous membranes.
Risk factors: Factors increasing the risks of HIV infection through occupational exposure include:
Amount of blood present on the needle or cutting material (visible blood)
Needle placed inside vein or artery, hollow-bore needle
Deep injury
Advanced stage in the source patient
High viral load in the source person
Acute infection in the source person
Post exposure prophylaxis: Recommended implementation:
Post exposure prophylaxis should be started as soon as possible.
PEP should be maintained for 4 weeks.
Testing after six weeks of exposure is essential to detect any possibility
of sero conversion
Indications for HIV post exposure prophylaxis PEP
Exposure type Asymptomatic,
Low viral load,
Adequate ART
Symptomatic,
Advanced,
Acute infection,
High viral load,
Not on ART
Source of
unknown HIV
status
Unknown source HIV
negative
Less severe
percutaneous
(solid needle,
superficial)
2- drugs PEP 3- drugs PEP No PEP.
Unless source
has HIV risk
factors
(2-drugs PEP)
No PEP.
Consider 2-drugs
PEP if exposure
to HIV infected
persons is likely
No PEP
More severe
percutaneous
(hollow bore
needle, visible
blood, needle in
vein or artery)
3- drugs PEP 3- drugs PEP No PEP.
Unless source
has HIV risk
factors
(2-drugs PEP
No PEP.
Consider 2-drugs
PEP if exposure
to HIV infected
persons is likely
No PEP
Indications for HIV post exposure prophylaxis PEP
Exposure type Asymptomatic,
Low viral load,
Adequate ART
Symptomatic,
Advanced,
Acute infection,
High viral load,
Not on ART
Source of
unknown HIV
status
Unknown source HIV
negative
Small volume
mucous
membrane or
non intact skin
2-drugs PEP 2-drugs PEP No PEP No PEP No PEP
Large volume
mucous
membrane or
non intact skin
2-drugs PEP 3-drugs PEP No PEP.
Unless source
has HIV risk
factors
(2-drugs PEP
No PEP.
Consider 2-drugs
PEP if exposure
to HIV infected
persons is likely
No PEP
Recommended regimens:
2 drugs PEP: This usually includes 2 NRTIs:
ZDV or D4T or TDF Plus 3TC or FTC
In a 3 drugs PEP, the third recommended drug it was a PI (LPV/r or
ATV/r or IDV/r.
Due to proved toxicity of most PI’s it is preferable now to use an NNRTI
as the third drug (EFV).
The National guidelines of treatment with ARD’s recommend
starting the triple drug regimen for all PEP eligible cases.
Follow-up of exposed health care worker:
1. Testing:
Immediately after report of exposure and along with the initiation of PEP
the HCW should be tested for HIV serology
Repeated testing should be offered at 6 weeks, 3 months and 6 months to
determine whether contamination occurred or not
Viral assays such as PCR are not indicated.
2. Counseling Exposed HCW should be counseled concerning the practice of protected sexual
activity as well as reproductive counseling throughout the period of observation and
until serology is definitive
They should be advised to use precautions (avoid blood or tissue donations, avoid
breastfeeding and pregnancy) for at least 12 weeks after exposure
The HCW should also be informed of the potential toxicities and possible drug
interactions of the PEP regimen used
Adherence to treatment should be emphasized.
The HCW should be counseled about the adherence to standard precautions in
his/her practice.
3. Hepatitis exposure
The source of exposure should be offered testing for HBV and HCV.
The HCW should also be tested for HBV and HCV antibodies.
Specific measures should be taken accordingly to prevent transmission of hepatitis
viruses to the HCW
If the patient source of exposure does not accept testing for hepatitis viruses, the
HCW should be managed as if the source was positive for these viruses.
• starting PEP should be initiated asap , preferably within the 1st 24 hours,
• it is not recommended to start PEP 72 hours after likelihood of exposure
• All cases of professional exposures of HCW and seroconversion
occurring after professional exposure should be reported as such to the
National AIDS Program.
Very important notes:
Please, always remember to keep safe.
THANK YOU
The National AIDS Program