Post exposure prophylaxis of hiv

Post Exposure prophylaxis guidelines for medical professional

1. Post Exposure prophylaxis of hiv

2. DR. NIRANJAN CHAVAN MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP, DIPLOMA IN ENDOSCOPY (USA) Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital Joint Treasurer Elect, FOGSI (2021-2024) Member Oncology Committee, SAFOG (2020 onwards) National Co-Ordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2021) Vice President MOGS (2020-2021) Scientific Secretary, AFG (2020-2021) Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16) Dean & Chief Content Director, HIGHGRAD E3 Courses Chairperson, FOGSI Oncology and TT Committee (2012-2014) Course Co-Ordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at L.T.M.G.H (2010-16) Member, Oncology Committee AOFOG (2013-2015) Member, Managing Committee IAGE (2013-17), (2018-20) Editorial Board, European Journal of Gynaec. Oncology (Italy) Course Co-Ordinator of 3 batches of Advanced Minimal Access Gynaec Surgery (AMAS) at LTMGH (2018-19)

3. “As long as the AIDS virus threatens the health and lives of people here and around the globe, our work will continue to connect people to treatment, educate them about how to protect themselves, battle discrimination, and to keep the country focused on our collective fight against this pandemic.” Secretary for Health and Human Services Kathleen Sebelius

4. hiv The human immunodeficiency viruses are virus that infect humans. Over time, they cause acquired immunodeficiency syndrome, a condition in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive. Without treatment, average survival time after infection with HIV is estimated to be 9 to 11 years.

5. Routes of transmission Unprotected sex Parent to Child Injecting Drug Use Blood and Blood products Unknown cause

6. Occupational hiv infection Occupationally acquired HIV infection among HCW reported in 6/99 137 possible cases of HIV transmission 57 documented cases of HIV infection – 26/57 have AIDS Most exposures do not result in infection

7. Factors influencing transmission Amount of blood involved in exposure Amount of virus in patient’s blood at time of exposure Post-exposure prophylaxis

8. Exposure risk RISKIEST - Dee p pa re nte r a l i no c u l at i o n v i a h o l l o w n eed l e , pa re nte r a l i no c u l a t i on wi t h h i g h v i r a l t i te r s LESS RISKY- Sm a l l v o l u m e v i a n on - h o l l o w n eed l e m u c o sal e x po s u r e/ n o n - i nt a ct sk i n e x po s u re RISK NOT IDENTIFIED - I n tact s k i n e x po sure e x po s u r e t o u r i n e, s a li v a, tea r s , s w eat

9. prevention Preventing exposures to blood and body fluids ( ie , primary prevention ) is the most important strategy for preventing occupationally acquired human immunodeficiency virus (HIV) infection. Both individual healthcare providers and the institutions that employ them should work to ensure adherence to the principles of Standard Precautions , including ensuring access to and consistent use of appropriate work practices, work practice controls, and personal protective equipment.

10. What is post exposure prophylaxis (pep)? PEP stands for post-exposure prophylaxis. PEP means taking HIV medicines within 72 hours after a possible exposure to HIV to prevent HIV infection. PEP should be used only in emergency situations. It is not meant for regular use by people who may be exposed to HIV frequently. PEP is not intended to replace regular use of other HIV prevention methods, such as consistent use of condoms during sex or pre-exposure prophylaxis ( PrEP ). PrEP is when people at risk for HIV take a specific HIV medicine daily to prevent getting HIV.

11. the goal The ultimate goal of PEP is to maximally suppress any limited viral replication that may occur, and to shift the biological advantage to the host cellular immune system to prevent or abort early infection.

12. Who needs pep? PEP may be prescribed for people who are HIV negative or don’t know their HIV status, and in the last 72 hours : May have been exposed to HIV during sex. Shared needles or other equipment (works) to inject drugs. Were sexually assaulted . An exposure that might place Health Care Personnel at risk for HIV infection is defined as a percutaneous injury ( eg , a needlestick or cut with a sharp object) or contact of mucous membrane or nonintact skin ( eg , exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious .

13.  In a retrospective case-control study of HCP who had percutaneous exposure to HIV, increased risk for HIV infection was associated with exposure to a larger quantity of blood from the source person as indicated by A device ( eg , a needle) visibly contaminated with the patient’s blood, A procedure that involved a needle being placed directly in a vein or artery A deep injury.

14. The risk also was increased for exposure to blood from source persons with terminal illness, likely reflecting the higher titer of HIV in blood late in the course of acquired immunodeficiency syndrome (AIDS). Taken together, these factors suggest a direct inoculum effect ( ie , the larger the viral inoculum, the higher the risk for infection)

15. Immediate measure Percutaneous: W a sh n e ed l est i cks an d c ut s w i t h s oa p an d w at er. Re m o ve f o r e i g n m at er i a l s. Non – Intact Skin Exposure: – W a sh wi t h s o ap a nd w ate r o r ant i s e p t i c Mucous Membrane: Flush splashes to the nose, mouth or skin with water Irrigate eyes with clean water, sterile saline or sterile irrigants .

16. Antiretroviral agents Antiretroviral agents from 6 classes of drugs are currently available to treat HIV infection. These include N ucleoside and nucleotide reverse-transcriptase inhibitors (NRTIs) Nonnucleoside reverse-transcriptase inhibitors (NNRTIs) Protease inhibitors (PIs) Fusion inhibitor (FI) Integrase strand transfer inhibitor (INSTI) Chemokine (C-C motif) receptor 5 (CCR5) antagonist.

17. For occupational exposure Preferred HIV PEP Regimen Raltegravir (RAL) 400 mg PO twice daily + Truvada, 1 PO once daily ( Tenofovir DF [ Viread ; TDF] 300 mg + E mtricitabine [ Emtriva ; FTC] 200 mg ) DURATION- 4 WEEKS if tolerated

18. Alternative Antiretroviral Agents for Use as PEP Only with Expert Consultation. Abacavir ( Ziagen ; ABC) Efavirenz ( Sustiva ; EFV) Enfuvirtide ( Fuzeon ; T20) Fosamprenavir ( Lexiva ; FOSAPV) Maraviroc ( Selzentry ; MVC) Saquinavir (Invirase; SQV) Stavudine ( Zerit ; d4T) Antiretroviral Agents Generally Not Recommended for Use as PEP Didanosine ( Videx EC; ddI ) Nelfinavir ( Viracept ; NFV) Tipranavir ( Aptivus ; TPV) Antiretroviral Agents Contraindicated as PEP Nevirapine ( Viramune ; NVP)

19. Points to remember  Occupational exposures to HIV should be considered urgent medical concern and treated immediately. For example, a surgeon who sustains an occupational exposure to HIV while performing a surgical procedure should promptly scrub out of the surgical case , if possible, and seek immediate medical evaluation for the injury and PEP .

20. Additionally, if the HIV status of a source patient for whom the practitioner has a reasonable suspicion of HIV infection is unknown and the practitioner anticipates that hours or days may be required to resolve this issue, antiretroviral medications should be started immediately rather than delayed.

21. Exposed personnel should be advised to use precautions to prevent secondary transmission, especially during the first 6–12 weeks after exposure. U se of barrier contraception A voidance of blood or tissue donations Pregnancy I f possible, breast-feeding Providing HCP with psychological counseling should be an essential component of the management and care of exposed HCP.

22. Follow up after exposure HCP who have experienced occupational exposure to HIV should receive follow-up counseling, postexposure testing, and medical evaluation regardless of whether they take PEP.  Careful attention to follow-up evaluation within 72 hours of exposure can 1. P rovide another (and perhaps less anxiety-ridden) opportunity to allow the exposed HCP to ask questions and for the counselor to make certain that the exposed HCP has a clear understanding of the risks for infection and the risks and benefits of PEP 2. Ensure that continued treatment with PEP is indicated.

23. 3. I ncrease adherence to HIV PEP regimens 4. M anage associated symptoms and side effects more effectively 5. P rovide an early opportunity for ancillary medications or regimen changes 6. I mprove detection of serious adverse effects 7. I mprove the likelihood of follow-up serologic testing for a larger proportion of exposed personnel to detect infection. Closer follow-up should in turn reassure HCP who become anxious after these events

24. Post exposure testing HIV testing at baseline and at 6 weeks, 12 weeks, and 6 months after exposure ; alternatively. If the clinician is certain that a fourth-generation combination HIV p24 antigen–HIV antibody test is being utilized, then HIV testing could be performed at baseline, 6 weeks after exposure, and 4 months after exposure. Complete blood counts and renal and hepatic function tests (at baseline and 2 weeks after exposure; further testing may be indicated if abnormalities are detected).

25. Source testing Whenever possible, the HIV status of the exposure source patient should be determined to guide appropriate use of HIV PEP. Although concerns have been expressed about HIV-negative sources who might be in the so-called window period before seroconversion ( ie , the period of time between initial HIV infection and the development of detectable HIV antibodies), no such instances of occupational transmission have been detected . Administration of PEP should not be delayed while waiting for test results . If the source patient is determined to be HIV negative, PEP should be discontinued, and no follow-up HIV testing for the exposed provider is indicated.

26. “An ounce of prevention is worth a pound of cure.” Benjamin Franklin