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Case Conference: 30 yo man with a potentially high risk

HIV exposure

Case Conference: 30 yo man with a potentially high risk

HIV exposure

November 23, 2005James M Sosman, MD

November 23, 2005James M Sosman, MD

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CaseCase• ID: GS is a 30 yo man who presents

• CC: high risk sexual exposure over the past weekend

• HPI: GS contacted the clinic Monday PM and spoke with my nurse via phone. He stated that he may have experienced a high risk sexual exposure the past weekend and wanted to know what he should do. My nurse got him in to see me in clinic that PM.

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CaseCase

• HPI (cont): GS states that he had unprotected receptive anal intercourse with a man he met at a bar Saturday night. He did not believe that the man ejaculated into him. GS stated that he usually uses condoms but had been drinking that evening and used “bad judgment”. GS did not know his sexual partner but had heard “rumors” that he might be HIV +.

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CaseCase• PMHx:

– No history of STD or genital warts– No surgical or medical problems– Denies a history or hemorrhoids or anal fissures– GS states he took a home HIV test last month which

was negative

• NKAD• Medications: none

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CaseCase

• SHx: – Worked as medical administrator– Lives alone, occasional ETOH no IDU no illicit drug

use– Considers himself homosexual

• ROS: denies urethral, anal or oral discharge, pain or trauma/bleeding

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CaseCase

• PE: GS was somewhat anxious. • VS: 125/80, 88, 18, 96.8 wt 210lbs with clothes/shoes

– Skin: no lesions, no tattoos, no warts– HEENT: no oropharyngial lesions with good

dentition– Back: no CVA or spinal tenderness– GU: normal penis and testes without lesions or

penile discharge– Rectal: no perirectal lesions or anal tenderness.

Prostate smooth and nontender

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CaseCase

• GS reports a potential high risk sexual exposure. What should we do?

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CaseCase

• Should we provide non-occupational post exposure prophylaxis with antiretroviral medication (nPEP)?

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Estimated per-act risk for acquisition of HIV, by exposure route*

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CaseCase

• Assessment of GS’s sexual exposure risk:

– Anal receptive intercourse from source with unknown HIV status

– < 72 hours since exposure

• Should we offer nPEP?

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Biologic Plausibility of PEPBiologic Plausibility of PEP

• Animal Models– Macaque SIV studies demonstrated efficacy of PMPA (tenofovir) in

blocking IV exposure to SIV if administered within 24hours and continued for 28 days

• Postnatal Prophylaxis– Abbreviated regimens of ART for reducing mother to child HIV

transmission have been extensively studied. Women receiving even a single dose of nevirapine at the beginning of labor and then one does to the neonate within 72 hours of delivery had a 50% reduction in transmission compared with those receiving AZT in a similar manner

• PEP for Healthcare Workers– AZT PEP for occupational needle-sticks can reduce the risk of HIV

transmission by 81%

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Risk Factors for HIV Transmission After Percutaneous Exposure to HIV-Infected Blood: CDC Case-Control

Study*

Risk Factors for HIV Transmission After Percutaneous Exposure to HIV-Infected Blood: CDC Case-Control

Study*

Risk Factor Adjusted OR ratio (95% CI)

Deep injury 15 (6.0-41)Visible blood on device 6.2 (2.2-21)Procedure involving needle 4.3 (1.7-12) placed in artery or veinTerminal illness in source patient 5.6 (2.0-16)Postexposure use of AZT 0.19 (0.06-0.52)

*Cardo et al., New Engl J Med 1997;337:1485-90.

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Mixed Results for non-occupational PEP (nPEP)Mixed Results for non-occupational PEP (nPEP)

• Only observational studies and case reports

• Sexual assault survivors in Brazil who sought care within 72hrs were treated for 28 days with AZT/3TC. Women assessed after 72hrs were not treated. Of 180 treated, none seroconverted but of 145 not treated, 4 (2.7%) seroconverted.

• Feasibility trial of nPEP in San Francisco, 401 persons with sexual or IDU exposure were enrolled. No seroconversions were observed in any group; those treated 28 days, treated < 28 days, or those not treated.

• Case report of a single patient receiving HIV tainted transfusion, started PEP 1wk later and continued for 9 months without seroconversion

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CDC Guidelines for nPEPCDC Guidelines for nPEP

• January 2005, CDC published guidelines regarding non-occupational HIV PEP

• nPEP guidelines may serve as a national standard similar to PEP for HIV exposure to HCWs

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CDC Guidelines for nPEPCDC Guidelines for nPEP

• non-occupational HIV exposure– any direct mucosal, percutaneous, or intravenous

contact with potentially infectious body fluids that occurs outside perinatal or occupational situations (eg, health care, sanitation, public safety, or laboratory employment).

• Potentially Infectious Body Fluids– blood, semen, vaginal secretions, rectal secretions,

breast milk, or other body fluid that is contaminated with visible blood

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Algorithm for evaluation and treatment of possible

non-occupational HIV exposures

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Algorithm for evaluation and treatment of possible

non-occupational HIV exposures

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Antiretroviral regimens for non-occupationalpost-exposure prophylaxis of HIV infection

Antiretroviral regimens for non-occupationalpost-exposure prophylaxis of HIV infection

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CaseCase

• GS was willing to take nPEP and reduce his risk of future sexual exposures:

– Started Truvada (Tenofovir/emtracidabine) qD for 28 days

– Baseline labs– GS could not confirm HIV status of sexual

contact

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Recommended HIV post-exposure prophylaxis (PEP) for percutaneous injuries in HCWs

Recommended HIV post-exposure prophylaxis (PEP) for percutaneous injuries in HCWs

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Post-Exposure Prophylaxis(PEP) Among HCWs for HIV Prevention

• Wang SA, et al. Infect Contr Hosp Epidemiol 2000;21:780

• Presented findings from the PEP Registry (CDC, FDA, HRSA, NIH)

• 492 enrolled HCWs with occupational exposure to HIV from October 1996 thru December 1998– Median time from exposure to initial PEP was 1.75

hours– No seroconversions at 6 wks for 449 HCWs– Adverse side effects noted in 76%

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CaseCase

• Offering a two-drug regimen is a viable option, primarily because the benefit of completing a full course of this regimen exceeds the benefit of adding the third agent and risking non-completion because of side-effects

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CaseCase

• GS’s W/U included:

– HIV antibody negative

– RPR negative

– Urine for GC and CT via LCX negative

– Hepatitis A and B serologies immune

– Hepatitis C antibody negative

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Recommended laboratory evaluation for non-occupational post-exposure prophylaxis (nPEP) of HIV

infection

Recommended laboratory evaluation for non-occupational post-exposure prophylaxis (nPEP) of HIV

infection

• Test Baseline 4-6wks 3 months 6months

• HIV Ab X X X X

• STD screen X X

• HBV serology X X X

• HCV serology X X X

• CBC/LFTs/Cr X during nPEP

• Pregnancy test X X

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CaseCase

• GS tolerated the medication without difficulty. He missed no dosed in the 28 day treatment:

– 6 week F/U labs included HIV(-), STD and RPR negative

• GS is employing safer sexual practices

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HIV PEP for Sexual Exposure in US ERs (Merchant, RC Am J Emerg Med 21:4; 2003)

HIV PEP for Sexual Exposure in US ERs (Merchant, RC Am J Emerg Med 21:4; 2003)

EXPOSURE RISK PEP OFFERED

Needle Stick Unknown 79%

High risk or HIV + 95-98%

Low risk 41%

Sexual Exposure Unknown 73%

High risk or HIV + 93-96%

Low risk 44%

Consensual Sex Unknown 45%

High risk or HIV + 84-89%

Low risk 22%

Circumstances for prescribing PEP

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Resources for evaluation and treatment of possible non-occupational HIV exposures

PEPline at http://www.ucsf.edu/hivcntr/Hotlines/

PEPline: telephone 888-448-4911

CDC (for reporting HIV infections in HCW and failures of PEP) at telephone 800-893-0485