Issues around HIV & post-exposure prophylaxis

Dr. Laura SauveOak Tree Clinic

Pre-departure trainingJune 2014

What are the risks if I get a needle stick / blood exposure to mucous membranes?HIVHepatitis B – vaccine preventable!!!Hepatitis C

For further details see: http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure

Hepatitis BTransmission: vertical, sexual, via needles /

blood (much more easily transmissible than HIV)

~2 billion people infected world wide ~240 million chronic infectionsVaccine preventable!

So, you shouldn’t be working as a health care worker if you are not vaccinated

Make sure you have protective titres before leaving

Hepatitis CTransmitted principally via needles / blood –

unsafe medical equipment, IDUUncommon in children, generallyHighest prevalence countries – adult

prevalence estEgypt (22%), Pakistan (4.8%) and China (3.2%)Less common in Sub-Saharan Africa (1.5-3.5%

estimated)Not vaccine preventable, no PEP

~3.3 million HIV infected children world wide

Most infections in sub-Saharan Africa

New Infections

Source: Towards an AIDS-Free Generation: UNICEF Stocktaking report

HIV Epidemiology in Children

South Africa: All Children 2-15, seroprevalence survey - 2.5% (95% CI:1.9

– 3.5%) (Source: http://www.childrencount.ci.org.za/indicator.php?id=5&indicator=29 ) Western Cape adults ~18%Red Cross Hospital inpatients, one day cross sectional

survey ~18% (S Afr Med J. 2006 Sep;96(9 Pt 2):993-5.)

Bangladesh:Adult HIV prevalence <0.1%; no estimate for children

(UNICEF)

BIPAI Clinics (all countries): Virtually 100% of outpatients

Uganda ~150,000 HIV infected children (UNICEF)

Risk of HIV transmission after a significant exposure (source known HIV infected)Percutaneous exposure risk 0.3% (1 in

300). Mucocutaneous exposure risk 0.1% (1 in

1,000).Factors which increase the risk of HIV

transmission include:High viral loadVisible blood on the device and/or a device

previously in a source’s artery or veinDepth of woundVolume of bloodGauge of needle in needlestick exposures

(larger bore needles carry greater risk because of the larger volume of blood exposure).

For further details see: http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure

What is a “significant exposure”Patient KNOWN to be HIV positive or high

risk* PLUS

Any percutaneous exposure to infectious body, fluids

Mucous membrane or non-intact skin, exposure, i.e. more than a few drops of blood and/or duration of exposure of several minutes or more.

* All inpatients in the Western Cape & generally in Subsaharan-Africa who are not already known to be HIV negative are “high risk”; adolescents may be in the “window period” so even if recently tested are “high risk”

Cases where there is a negligible risk of transmissionSource known to be HIV negative ORHIV infected source with

Minor percutaneous, mucous membrane or skin exposure to non-infectious body fluid.

Intact skin exposure to a small quantity of blood (less than three drops) or fluid visibly contaminated with blood of short duration i.e. less than three minutes.*

Bites unless there has clearly been transmission of infected blood.

A superficial scratch which does not bleed.Injuries received in fights would rarely be

appropriate indications for prophylaxis unless it is clear that transfer of infected blood has occurred.No PEP recommended

What if source was thought to be high risk but status not known?Assume they are infected; HIV serology

should be done (with parental consent)Check local protocols (ideally prior to a

needle stick!)“High Risk”:

All inpatients in the Western Cape & generally in Subsaharan-Africa who are not already known to be HIV negative

Adolescents; they may be in the “window period” so even if recently tested negative are “high risk”

What is PEP & the side effectsTenofovir: 1 tab (300 mg) once a day for 28 days

well tolerated and side effects are mild. They may include nausea, diarrhea and gas.

Rarely, liver or kidney changes. Lamivudine (3tc): 1 tablet (150 mg) twice a day for 28 days

usually well tolerated in short-term therapy and side effects are rare. Reversible decreased white blood cell count is the commonest side effect.

Tingling of the hands and feet (peripheral neuropathy) is very unlikely to occur with one month of treatment.

Kaletra: two tablets twice a day with meals for 28 daysSide effects include diarrhea, nausea, vomiting and abdominal pain. Occasionally there will be changes in liver function tests. Kaletra

may interact with a wide number of medications.

What do I have to consider before starting PEP after an exposure?Toxicity – drugs often not well tolerated by

health care workers on PEP.Need to start ASAP – ideally within 2 hours

of exposureMany drug interactions if there are any other

medications

Why take PEP:HIV infection is lifelong and has major

health implications.Markedly reduce the risk of transmission

of HIVARVs taken for one month have few long-

term side effects despite significant short term morbidity.

If ARVs are taken and HIV infection still occurs, the early use of antiretrovirals may favourably alter the course of subsequent infection.

Summary: Prevention! Discuss with your preceptor before it

happens – what to do in that hospitalMost important: Try to avoid a needlestick or

splash!!!Careful use of universal precautionsGlovesEye protectionCareful needle disposal

Summary: if a needlestick arisesFirst aid – wash with lots of water & soapDiscuss with your preceptor

If in South Africa, consider discussing with an expert in HIV / occupational exposures.

Contact program director urgentlySerology on source & yourself (HIV, Hep B,

Hep C)If high risk percutaneous injury & presumed

HIV infected source, start PEPIf lower risk setting, consider PEP.

If you want to take PEP with youCosts…

5 day PEP starter kit ~$2501 month PEP ~$1000Could consider buying a kit & if unused,

passing it on to the next residentAsk your on site supervisor if PEP is available

in your elective site for purchaseDiscuss with your travel health physician and

consider discussing with Center for Excellence in HIV / AIDS pharmacy staff: 1-888-511-6222

Center for Excellence in HIV / AIDSClinical guidelines:

http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure

CFE Pharmacy: 1-888-511-6222