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Post-Exposure Prophylaxis

Post-Exposure Prophylaxis

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Post-Exposure Prophylaxis

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  1. Post-Exposure Prophylaxis Dr Michael J. Boyle

  2. Common presentations • Needle in the park • Heterosexual sex - Vaginal - Oral • Male to male sex - Anal - Oral • Rape - Heterosexual - male to male • Needle sharing / needle assault • Other - trauma, dermatitis, broken skin exposure

  3. Assessing the risk 1. The exposure - type of sex - type of injecting equipment - nature of injury (needle gauge) - nature and volume of body fluid - time since exposure 2. The source - Known +ve - source VL if known; Stage of HIV - If status unknown, ? epi risk

  4. Management: First Steps • Clean wound (soap and water) No Caustic agents • Flush mucous membranes with saline • Vaginal/rectal douching not recommended • Assess tetanus hepatitis B vaccination status • Organise pre-test counselling • Risk assessment: risk of exposure X Source risk • Factors that may enhance that risk assessment

  5. Type of Exposure Receptive anal intercourse Receptive vaginal intercourse Insertive vaginal or anal Needle injury Using contaminated needles Mucous membrane HIV Transmission Risk < 3.0% (1 in 125 to 1 in 30) < 0.1% (1 in 2000 to 1 in 667) < 0.1% (1 in 3333 to 1 in 1111) ~ 0.3% (1 in 313) ~ 0.6% (1 in 149) ~ 0.1% (1 in 1111) Current HIV seroprevalence in Australia (0.066%) Homosexual men 3-15% Injecting drug users ~1% Homosexual male IDU 17% Heterosexual STD clinic attendees 0.1% Blood donor 0.0005%

  6. Epidemiological risk varies

  7. Other Risk Factors and Balancing Risk • ? Patient viral load, treatment history • ? Presence of STI in source or exposed person • ? Ulcerative or inflammatory oral disease if oral sex • ? Volume of blood if needle exposure • 1 in 6 million for death from bee sting per year • 1 in 5 million for childhood kidnap per year • 1 in 2 million die by lightning strike each year • 1 in 800 die due to smoking-related illnesses

  8. Management: What needs to be discussed • Pre-test counselling (may be delayed) • Risk carefully explained • HIV pep is NOT a proven therapy • 4 week therapy (can be difficult) • Protection for others (condom, needle sharing, breast feeding, blood donation, safe work practices) • Side effects of drugs (don’t confuse seroconversion) • Risks in pregnancy • It is the choice of the patient and can stop anytime • Need for follow-up • Counselling and support ! ! ! ! !

  9. Drug therapy Consider: • Unprotected receptive or insertive anal intercourse • Sharing needles and syringes • Unprotected receptive or insertive vaginal sex • Mucous membrane or non-intact skin exposure to HIV-positive blood Lesser risk, but consider • Unprotected receptive fellatio if source known positive AND recipient • Mucous membrane, non-intact skin exposure to HIV-infected secretions • ALSO, source should be known positive, or at epidemiological high risk • Also, consider whether presents within 72 hours

  10. The drugs: which one • 2 drugs most commonly: combivir • Factor in drug history of source • ALWAYS consult when prescribing • 3 drugs if known Positive source AND advanced disease High viral load Has resistant virus • Never use nevirapine

  11. Document For exposed individual • Nature, time of exposure, factors in exposure, time seen • Recent HIV testing, previous exposures, pep use • Current STIs; history of other STIs; Hep B,C history • Pregnant? breast feeding? • Significant medical disease, medication • Discussion around PEP understanding, risk/benefit, treatment decision and what was recommended • Consent for baseline testing after pre-test counseling: HIV, pregnancy, hepatitis B and C, blood count, LFT For source individual • HIV stage, CD4 count, viral load, retroviral history, resistance tests • hepatitis status, Hepatitis B infectivity, hepatitis C Viral load • STI history: present and past infections

  12. Management: what else to consider • Tetanus • Hepatitis B • Hepatitis C • Other STIs • Sepsis (Staphylococcal infection in IDU)

  13. Management: Hepatitis B • If ever PROVEN immune to hepatitis B by vaccine or infection, no need for further therapy • If non-immune, commence vaccination +/- HBIg within 72hours. • If previously completed full vaccination >90% protected • sAg positive; eAg, DNA positive: 30-40% • sAg pos; eAg, DNA neg: < 6%

  14. Hepatitis C Risks • High prevalence in drug users • If sero-positive, risk for needlestick 1.8% • If RNA positive, risk of needlestick 10% • Potential benefit of early treatment during seroconversion • Follow up testing via serology +/- LFT, viral assessment

  15. Follow up • Post-test counselling • 3 months follow up for HIV if no PEP • 6 months follow up for HIV if PEP given • 6 months follow up for hepatitis B and C • Advice re avoiding future exposures