POST-EXPOSURE PROPHYLAXIS

FOR HIV

CDC Guidelines
September 2009
 The term “Post-exposure prophylaxis” or PEP
refers to the prophylactic use of
antiretrovirals to prevent establishment of
HIV infection after an occupational exposure
to HIV
 Percutaneous
◦ Needle stick
◦ Sharps injury
 Mucocutaneous

 Contact with skin which is abraded,

chapped, inflamed or an open wound

 Direct contact with concentrated HIV in a

laboratory
 Isolated skin exposure
 Hepatitis B virus 6-30%

 Hepatitis C virus 1.8%

 Human
Immunodeficiency Virus 0.3%
 Who is at risk?
 What is the risk?
 What are the factors which influence the
risk?
 How can the risk be reduced?
 What is the role of antiretrovirals in
reducing the risk?
 All HCP who come in contact with
blood or bloody fluids in hospitals or
laboratories
 Nurses, laboratory workers, doctors,
residents, paramedics, emergency
doctors, medical students
Occupational
Percutaneous 0.3%
Mucous membrane 0.09%
Sexual transmission 0.018% to 3%
Mother to child 25%
Infected blood products 95%

Antiviral therapy 1998; 3 (Suppl 4): 45-47

 Depth of injury
 Size and type of needle
 Device visibly contaminated with blood
 Procedure involving a needle placed in

artery or vein
 Use of zidovudine
 Source patient’s viral load
 Blood, bloody fluids
 Potentially infectious: semen, vaginal
secretions, CSF, pleural, peritoneal,
pericardial, amniotic fluids or tissue
 Faeces, nasal secretions, saliva,
sputum, sweat, tears, urine and
vomitus not considered potentially
infectious unless they are visibly
bloody
 Hands
 Body contact in cases of
increased blood loss
 Face contact, common in
orthopaedics and obstetrics
 Eye/mucous membrane
contact
 Number of procedures
 Double gloves
 Gowns, facemasks, goggles. Care during
procedures such as endoscopy, ENT
surgery, others where splattering of blood
is anticipated
 Use of impervious needle-disposal
containers
 Transport of samples in sealed containers
 Universal precautions
•Undiluted Savlon solution
•Chlorhexidine
•2% glutaraldehyde
•Household bleach
•Formalin 4%
•Povidone iodine 2%
•IPA, ethanol 70%

•Dettol solution – no effect

 Protocols for evaluation,
counselling and treatment of
occupational exposures
 Access to clinicians during all
hours
 Availability of antiretroviral agents
for PEP on-site or easily
 Availability of trained personnel for
counselling
 56 cases of documented HIV transmission
 136 possible cases
 49 cases – percutaneous; 5 –
mucocutaneous
 50 cases involved blood; 3 cases involved
concentrated virus in the lab; 1 case -
bloody body fluid; 1 - unspecified body
fluid
 Inhalation of aerosolized blood or other
secretions, intact skin contact, sustained
patient contact – no risk
 What is the source material?
 What is the kind of
exposure?
 What is the status of source
person/specimen?
(HIV positive, end-stage disease,
primary HIV infection, unknown)
 Is the HCP pregnant?
 Use of soap and water to wash any wound or
skin
 Flush exposed mucous membrane with water
 Open wounds - irrigate with sterile saline or
disinfectant solution
 Eyes should be irrigated with clean water,
saline or sterile eye irrigants
 Report to the concerned authority
 Counselling
 Antiretroviral therapy
 Therapy should be recommended after exposure
 Therapy should be initiated as soon as possible,
preferably within hours of exposure
 2- and 3-drug regimens, based on level of risk
 Source patient’s HIV status unknown, decide on a
case-to-case basis
 Follow up counseling and HIV testing using ELISA
periodically for at least 6 months (baseline, 6
weeks, 12 weeks and 6 months)
 Potential benefits should be weighed against
potential risks
POST EXPOSURE PROPHYLAXIS FOR HCP
Source material: blood, bloody fluid, other potentially infectious fluid

Type of exposure

Mucous membrane or Intact Skin Percutaneous

non-intact skin exposure
(no PEP needed)
Volume
Severity

See Table 1
See Table 2
  Infection status of source
 
 
Exposure HIV-positive HIV-positive Source of Unknown HIV-
type class 1 class 2 unknown source negative
HIV status

Small Consider Recommend Generally, Generally, No PEP

volume basic 2-drug basic 2-drug no PEP no PEP warranted
PEP PEP warranted warranted

Large Recommend Recommend Generally, Generally, No PEP

volume basic 2-drug expanded > no PEP no PEP warranted
PEP 3-drug PEP warranted; warranted;
however, however,
consider consider
basic 2- basic 2-
drug PEP†† drug PEP
for source in settings
with HIV in which
risk factors exposure
to HIV-
infected
persons is
likely
  Infection status of source
 
Exposure
HIV-positive HIV-positive Source of Unknown HIV-negative
type
class 1 class 2 unknown HIV source
status

Less severe Recommend Recommend Generally, no Generally, no No PEP

basic 2-drug expanded > 3- PEP PEPwarranted warranted
PEP drug PEP warranted; ; however,
however, consider basic
consider basic 2-drug PEP in
2-drug PEP settings in
for source with which
HIV risk exposure to
factors HIV-infected
persons is
likely
More severe Recommend Recommend Generally, no Generally, no No PEP
expanded 3- expanded > 3- PEP PEPwarranted warranted
drug PEP drug PEP warranted; ; however,
however, consider basic
consider basic 2-drug PEP in
2-drug PEP settings in
for source with which
HIV risk exposure to
factors HIV-infected
persons is
likely
Preferred Alternate
 Duovir 1 tab bid • Lamivir-S 30/40 1

Or tab bid
 Tenvir 1 tab od + Or
• Dinex-EC (ab od +
Lamivir 1 tab bid or
2 tabs od Lamivir 1 tab bid or
2 tabs od
Or
 Tenvir-EM 1 tab od
Preferred Alternative
 Lopimune 2 tabs bid • Atazanavir 400 mg od*
Or
• Indivan 2 caps bid and
Ritomune 1 tab bid
Or
• Indivan 2 caps tid
Or
• Maximune 2 tabs and
Ritomune 1 tab bid
Or
• Nelvir 3 tabs tid
Or
• Efavir-600 1 tab od at
bedtime

*if used with TDF, use boosted

ATV
 Baseline HIV testing
 Follow up testing at 6 weeks, 3 months and 6

months by ELISA
 Role of HIV DNA PCR – unclear. If done must

be confirmed by ELISA
 Monitor for drug toxicity (minimally,
CBC and LFT at baseline and at 2 wks)
 Evaluation of symptoms such as rash,

fever, hyperglycemia, back or abdominal

pain or pain on urination should not be
delayed
 Potential drug interactions

 Failures can still occur

 Behavioural modifications
 More and more patients with HIV infection
continue to seek treatment
 Greater number of needlestick injuries are

expected to occur
 The risk of HIV transmission is extremely

small
 The availability of PEP should not preclude

taking universal precautions

THANK YOU