PEP for HIV Prevention Mostafa El Nakib MD,MPH

N.A.P

WHAT is PEP

Post- exposure prophylaxis (PEP) is a short-term antiretroviral treatment to reduce

the likelihood of HIV infection after potential exposure to the virus either:

1. Occupationally (accidental exposure to the virus)

2. Trough sexual intercourse

Within the health sector , PEP should be provided as part of a comprehensive

universal precautions package that reduces staff exposure to infectious hazards at

work

Why it is important

The risk of transmission of HIV from an infected patient through a needle stick where

the skin is punctured by a sharp is less than 1%

The risk of transmission from exposure to infected fluids or tissues is believed to be

lower than for exposure to infected blood

The risk of exposure from needle sticks and other means exists in many settings

where protective supplies are limited and the rates of HIV infection in the patient

population are high

The availability of PEP may reduce the occurrence of occupationally acquired HIV

infection in health care workers

It is believed that the availability of PEP for health workers will serve to increase staff

motivation to work with people infected with HIV and may help to retain staff

concerned about the risk of exposure to HIV in the workplace

There is a significant debate on the need to use PEP after exposure.

The MOPH offers PEP for free for the occupational exposure and

rape cases only

The UN offers PEP to its staff in cases of rape and when the

likelihood of HIV exposure is considered high ,special high risk

behaviors are included as well

Prevention of exposure

Prevention of exposure to the HIV remains the most

effective measure to reduce the risk of viral transmission to

health workers:

By applying the prevention methods (universal

precautions) .

By providing them with the necessary materials

and protective equipment .

Managing occupational exposure to HIV

First aid should be given immediately after the injury : wounds and skin sites exposed to blood or body fluids should be washed with soap and water , and mucous membranes flushed with water

The exposure should be evaluated for potential to transmit HIV infection ( based on body substance and severity of exposure)

The exposure source should be evaluated for HIV infection. testing of source persons should only occur after obtaining informed consent, and should include appropriate counseling and care referral. Confidentiality must be maintained

Clinical evaluation and baseline testing of the exposed health care worker should proceed only after informed consent

Exposure risk reduction education should occur with counselors reviewing the sequence of events that proceeded the exposure in a sensitive and non-judgmental way.

GUIDELINES FOR POST-EXPOSURE PROPHYLAXIS (PEP)

The implementation of standard infection control

practices should avert the risks of exposure to

potential risks of acquiring blood borne pathogens

including HIV.

An exposure is considered risky when occurring through percutaneous injury 1. a needle

2. cut with a sharp object

Also:

1. contact of mucous membrane

2. non intact skin with blood, tissue, other body fluids that are potentially

infectious

The following body secretions are considered potentially infectious: Blood

visibly bloody body fluids

semen and vaginal secretions

cerebrospinal fluid

synovial fluid

pleural fluid

peritoneal fluid

pericardial fluid

Amniotic fluid

The following body secretions are not considered potentially infectious unless they are visibly bloody:

Feces nasal secretions

saliva

Sputum sweat

tears

urine

vomitus

The average risk of transmission via a percutaneous route has been estimated at

approximately 0.3%

The risk from biological fluids other than blood is less.

Exposure of non intact skin is estimated to be much less and even

lower than exposure through mucous membranes.

Risk factors: Factors increasing the risks of HIV infection through occupational exposure include:

Amount of blood present on the needle or cutting material (visible blood)

Needle placed inside vein or artery, hollow-bore needle

Deep injury

Advanced stage in the source patient

High viral load in the source person

Acute infection in the source person

Post exposure prophylaxis: Recommended implementation:

Post exposure prophylaxis should be started as soon as possible.

PEP should be maintained for 4 weeks.

Testing after six weeks of exposure is essential to detect any possibility

of sero conversion

Indications for HIV post exposure prophylaxis PEP

Exposure type Asymptomatic,

Low viral load,

Adequate ART

Symptomatic,

Advanced,

Acute infection,

High viral load,

Not on ART

Source of

unknown HIV

status

Unknown source HIV

negative

Less severe

percutaneous

(solid needle,

superficial)

2- drugs PEP 3- drugs PEP No PEP.

Unless source

has HIV risk

factors

(2-drugs PEP)

No PEP.

Consider 2-drugs

PEP if exposure

to HIV infected

persons is likely

No PEP

More severe

percutaneous

(hollow bore

needle, visible

blood, needle in

vein or artery)

3- drugs PEP 3- drugs PEP No PEP.

Unless source

has HIV risk

factors

(2-drugs PEP

No PEP.

Consider 2-drugs

PEP if exposure

to HIV infected

persons is likely

No PEP

Indications for HIV post exposure prophylaxis PEP

Exposure type Asymptomatic,

Low viral load,

Adequate ART

Symptomatic,

Advanced,

Acute infection,

High viral load,

Not on ART

Source of

unknown HIV

status

Unknown source HIV

negative

Small volume

mucous

membrane or

non intact skin

2-drugs PEP 2-drugs PEP No PEP No PEP No PEP

Large volume

mucous

membrane or

non intact skin

2-drugs PEP 3-drugs PEP No PEP.

Unless source

has HIV risk

factors

(2-drugs PEP

No PEP.

Consider 2-drugs

PEP if exposure

to HIV infected

persons is likely

No PEP

Recommended regimens:

2 drugs PEP: This usually includes 2 NRTIs:

ZDV or D4T or TDF Plus 3TC or FTC

In a 3 drugs PEP, the third recommended drug it was a PI (LPV/r or

ATV/r or IDV/r.

Due to proved toxicity of most PI’s it is preferable now to use an NNRTI

as the third drug (EFV).

The National guidelines of treatment with ARD’s recommend

starting the triple drug regimen for all PEP eligible cases.

Follow-up of exposed health care worker:

1. Testing:

Immediately after report of exposure and along with the initiation of PEP

the HCW should be tested for HIV serology

Repeated testing should be offered at 6 weeks, 3 months and 6 months to

determine whether contamination occurred or not

Viral assays such as PCR are not indicated.

2. Counseling Exposed HCW should be counseled concerning the practice of protected sexual

activity as well as reproductive counseling throughout the period of observation and

until serology is definitive

They should be advised to use precautions (avoid blood or tissue donations, avoid

breastfeeding and pregnancy) for at least 12 weeks after exposure

The HCW should also be informed of the potential toxicities and possible drug

interactions of the PEP regimen used

Adherence to treatment should be emphasized.

The HCW should be counseled about the adherence to standard precautions in

his/her practice.

3. Hepatitis exposure

The source of exposure should be offered testing for HBV and HCV.

The HCW should also be tested for HBV and HCV antibodies.

Specific measures should be taken accordingly to prevent transmission of hepatitis

viruses to the HCW

If the patient source of exposure does not accept testing for hepatitis viruses, the

HCW should be managed as if the source was positive for these viruses.

• starting PEP should be initiated asap , preferably within the 1st 24 hours,

• it is not recommended to start PEP 72 hours after likelihood of exposure

• All cases of professional exposures of HCW and seroconversion

occurring after professional exposure should be reported as such to the

National AIDS Program.

Very important notes:

Please, always remember to keep safe.

THANK YOU

The National AIDS Program