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 - Deep parenteral inoculation via hollow needle,
– parenteral inoculation with high viral titers
LESS RISKY- Small volume via non-hollow needle
– mucosal exposure/non-intact skin exposure
RISK NOT IDENTIFIED-Intact skin exposure
– exposure to urine, saliva, tears, sweat

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.

11. 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.

12. 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.

13. 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.

14. • 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.

15. • 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)

16. IMMEDIATE MEASURE
• Percutaneous:
– Wash needlesticks and cuts with soap and water.
– Remove foreign materials.
• Non – Intact Skin Exposure:
– Wash with soap and water or antiseptic
•Mucous Membrane:
– Flush splashes to the nose, mouth or skin with
water
– Irrigate eyes with clean water, sterile saline or
sterile irrigants.

17. ANTIRETROVIRAL AGENTS
• Antiretroviral agents from 6 classes of
drugs are currently available to treat HIV
infection.
• These include
• Nucleoside 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.

18. • 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 + Emtricitabine
[Emtriva; FTC] 200 mg)
• DURATION- 4 WEEKS if tolerated

20. 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)

21. 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.

22. • 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.

23. • Exposed personnel should be advised to use precautions to prevent secondary
transmission, especially during the first 6–12 weeks after exposure.
• Use of barrier contraception
• Avoidance of blood or tissue donations
• Pregnancy
• If possible, breast-feeding
• Providing HCP with psychological counseling should be an essential component of
the management and care of exposed HCP.

24. 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. Provide 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.

25. • 3. Increase adherence to HIV PEP regimens
• 4. Manage associated symptoms and side effects more effectively
• 5. Provide an early opportunity for ancillary medications or regimen changes
• 6. Improve detection of serious adverse effects
• 7. Improve 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

26. 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).

27. 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.

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