Post Exposure Prophylaxis Post Exposure Prophylaxis for HIVfor HIV

Dr Abhimanyu MakaneMBBS CHIV FHM(CMC,Vellore) AAHIVSConsultant HIV PhysicianSterling Multispecialty Hospial,Nigdi,PuneAditya Birla Memorial Hospital,Pune

Can someone become HIV Can someone become HIV negative after diagnosis???negative after diagnosis???Mississippi BabyThe Berlin Patients

Outline Outline Principal changes from previous

PEP guidelinesHealth care personnel and

exposureRisk of transmission of HIVRecommendations for the management

of person potentially exposed to HIV◦HIV PEP

Source patient testing Timing and duration of PEP Selection of PEP drugs

◦Follow-up of exposed person Post-exposure testing Monitoring and management of PEP toxicity

Basis of PresentationBasis of PresentationWHO Adult ARV guidelines

supplement-Dec 2014DHHS Aug 2013 PEP guidelines

Principal Changes from Principal Changes from Previous PEP GuidelinesPrevious PEP GuidelinesElimination of risk stratification

for exposure incidents3-drug (or more) PEP regimen for

all

Occupational Risk Exposures Occupational Risk Exposures in HCPin HCPPercutaneous

injury (needle-stick, cut)

OR

Contact of mucous membrane or non-intact skin

WITH:

•Blood•Tissue•Other potentially infectious body fluids-(CSF, synovial, pleural, pericardial, peritoneal, or amniotic fluids; semen or vaginal secretions)

NOT Considered Infectious NOT Considered Infectious for HIV for HIV FecesNasal SecretionsSalivaSputum

Sweat TearsUrine Vomitus

Risk of Transmission of Risk of Transmission of HIVHIV

Assessment of the exposed Assessment of the exposed personperson4th generation ELISA for HIV HBV

◦Vaccination status

Source Patient HIV Source Patient HIV TestingTestingIf possible, determine the HIV status of

exposure source ◦ Unknown HIV status◦ Window period

HBVHCV

Timing and Duration of Timing and Duration of PEPPEPEffect inversely proportional to time to

initiation◦ ASAP preferably within hours◦ Point at which no benefit -not definedPEP should be taken for 4 weeks, if

tolerated◦ Appeared protective in occupational and

animal studies

Post-exposure prophylaxis Post-exposure prophylaxis ARV regimens-for AdultsARV regimens-for AdultsTDF + 3TC (or FTC)

◦The preferred backboneRAL, LPV/r, ATV/r or DRV/r

◦Preferred third drugEFV

◦Alternative options

ARV contraindicated as ARV contraindicated as PEPPEPNevirapine

Special ConsiderationsSpecial ConsiderationsPregnantBreastfeedingPaediatric

Follow-up of Exposed Follow-up of Exposed PatientPatient If 4th-generation (p24 Ag/HIV Ab test) is

used: HIV testing at baseline, 6 weeks, 12 weeks

after exposureBarrier Protection for partner protection Close follow-up to diagnose toxicities early

Assess

Counsel &

Support

Prescriptio

n

Followup

• Clinical assessment of exposure• Eligibility assessment for HIV PEP• HIV testing of exposed people and source if possible

• Risk of HIV• Risks and benefits of HIV PEP• Adherence counselling if PEP to be prescribed

• PEP should be initiated ASAP post exposure• 28-day prescription

• HIV test at 3 months after exposure• Link to HIV treatment if possible• Provision of prevention intervention as appropriate