Pre and Post Exposure

Prophylaxis (PrEP and

PEP)

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 Pre-Exposure
Prophylaxis (PrEP)

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Learning objectives
By the end of this session, participants
should be able to:
 Define Pre-exposure prophylaxis (PrEP)

 Describe the at risk populations

 Name the eligibility criteria for PrEP

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Definition of PrEP
Pr- Before
E- Exposure (risky behaviors that can lead to
acquisition of HIV)
P- Prophylaxis (prevention)

• PrEP is the use of ARV drugs by HIV negative

persons to prevent the acquisition of HIV
before exposure to HIV

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Facts about PrEP

 PrEP is being rolled out as a public health

intervention for HIV in Malawi
 PrEP neither protects against other STIs
nor prevents from pregnancy
 PrEP should be used in combination with
other HIV prevention methods such as
consistent condom use, VMMC, etc 5
Targeted Population(1)
 PrEP should be offered to HIV negative
high risk individuals for HIV infection which
include;
 Individuals who buy or sell sex
 STI clients for the past 6 months
 Adolescent girls and young women (AGYW) [15
– 24 years] having a sexual relationship with a
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Targeted Population(2)
 Key Populations (FSW, MSW, MSM,
PWID, Prisoners and Transgender)
 Sero-discordant couples
 HIV negative women with pregnancy or
breast feeding
 OR the HIV positive sexual partner is;

 Not on ART
 On ART <6 month
 With unsuppressed or high VL
 Poor adherent. 7
 Eligibility criteria for PrEP
include:
 Confirmed HIV negative
 Body weight of ≥30 kgs
 Age ≥15years
 No suspicious of acute HIV infection
 At substantial risk of acquiring HIV infection
 Willingness to take PrEP as prescribed
 No Contraindications to TDF/3TC

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 Women and PrEP

Additional information for women:

 PrEP does not affect the efficacy of hormonal
contraceptives.
 Taking them together does not make them
less effective
 PrEP does not protect against pregnancy.
 PrEP is safe and can be continued during
pregnancy and breastfeeding
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Minimum Requirements for
provision of PrEP in facility
 Have minimum of 2 PrEP trained clinical health
workers (Nurses/Clinicians)
 Availability of SOPs for PrEP provision
 Functioning laboratory or nearest health facility for
laboratory tests
 A well secured Pharmacy for commodity storage
 Rooms for service provision i.e. STI, Family
Planning Clinics
 Good M & E system and tools
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Entry Point for PrEP
PrEP is integrated into specific entry points of the public
health system and the following are priority entry points:
 HTS
 STI Clinics
 Family Planning
 Antenatal Care clinic
 Drop-in Centers (DIC’s)
 Youth Friendly Health Services Clinic
 One Stop Centre
 Gynaecology Clinic

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Starting of PrEP

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 PrEP Use

F I G U R E 1.
PrEP Us e

End of
1 DAY
7 DAY risk 7 DAY

I niti ate PrE P PrE P b e c o m e s d ays after

effe ctiv e last p ote ntial
ex p os ure, PrE P
can be
disc o nti n u e d

• At least 7 days of PrEP are needed before you achieve maximum

protection from HIV
• You can stop PrEP 7 days after your last exposure if you are no
longer at substantial risk
NOTE :
Clients are to continue taking prep throughout the period of high risk
and must not stop after achieving maximum protection at 7 days to
avoid sero-conversion 13
Event-Driven Oral PrEP
 Taking PrEP pills only when you are at risk
for getting HIV.
 Also called On-Demand PrEP or 2+1+1.
 Is effective in reducing the likelihood of HIV
acquisition during sex for people assigned
male at birth
 Offer ED-PrEP to all men (men who have sex
with women and men who have sex with
men)
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2-1-1 Schedule
 This means taking 2 pills 2 to 24hours before
sex, 1 pill 24 hours after the first dose, and 1
pill 24 hours after the second dose.

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Event-Driven PrEP Criteria
Eligible
 Offer ED-PrEP to all men (who
have sex with women and men
who have sex with men):
1. Find ED-PrEP more convenient
2. Have infrequent sex (e.g., less
than 2 times a week on average)
3. Can plan for sex 2 hours in
4. advance, or who can delay sex
at least for 2hours
Not eligible
 Women and transgender
women who are on female
hormonal treatment
 Men and trans and gender
diverse people who:
 Who injects drugs
 Take hormonal
treatment
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 PrEP Regimen for Malawi
 Tenofovir Disoproxil Fumarate (TDF/3TC) is
the preferred PrEP regimen for Malawi
 Tenofovir / Emtricitabine (TDF/FTC) can be
given as an alternative
 The following tests need to be conducted
before an individual is initiated on PrEP:
 HIV test
 Hepatitis B surface antigen

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PrEP and other drug interactions

 PrEP doesn’t have any known interactions with

hormonal Contraceptives
 PrEP doesn’t interact with alcohol or
recreational drugs
 PrEP provider should discuss behaviour
change with the client who uses alcohol or
other substances on PrEP adherence

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Client Follow Up Visit Procedures(1)
 Indicate follow up schedules;
 At 1 month, 3 months and then every 3
months after initiation
 Confirm HIV-negative status at every visit (if
positive, refer for ART)
 If poor adherence, identify barriers and provide
support as appropriate
 Emphasize the limitations of PrEP if not taken
daily and discuss other prevention methods
(e.g. condom use) 19
Client Follow Up Visit Procedures (2)

 Assess tolerability, side effects, and effective use

and manage side effects
 Assess need for contraceptives
 Provide STI screening and treatment
 Provide appropriate refill

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Management of PrEP Clients in
Specific Situations (1)

Inconclusive HIV test result during follow-up

visit
 Discontinue PrEP
 Repeat rapid HIV antibody test in 2 weeks

 Only after a confirmed HIV negative result,

client can continue with PrEP
 Strongly emphasize condoms use during the
period with inconclusive HIV test results
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Management of PrEP Clients in
Specific Situations (2)
Seroconverts while on PrEP
 Identify reasons for sero conversion;
 E.g. non- adherence, stopped taking PrEP,
or PrEP failure
 Document clearly that client seroconverted on
PrEP and that client should be monitored
closely for possible failure

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 Key Points
 PrEP is offered to clients who are HIV
negative and are at substantial risk of
acquiring HIV
 Eligible clients will be initiated on PrEP
 At follow- up visits, clients will be scheduled
for clinical ,lab and adherence assessments

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 Post-Exposure
Prophylaxis (PEP)

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 Learning Objectives
By the end of the session participants will be
able to:
 Define Post-Exposure Prophylaxis (PEP)
 Describe measures to be taken when risk of
transmission has occurred

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Definition
 Post exposure prophylaxis is a short course
of HIV medicines taken very soon within 72
hours after a possible exposure to HIV.

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 Eligibility to start PEP
 Any exposure classified as risky in the past 72
hours
 Never refuse PEP on a moral judgement
about the circumstances of exposure
 New HIV test is mandatory to confirm negative
HIV status – BUT don’t delay starting PEP if
HTC is not immediately available
 PEP can be given in pregnancy & breastfeeding
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 Key Facts (1)
 HIV infection can be prevented after a high risk
contact with body fluids from an HIV-infected
person
 Immediately remove as much as possible of the body
fluid
 Obtain HIV test to verify HIV status of the person who
was exposed
 Immediately start a 30-day course of ARV prophylaxis
(PEP) if exposed person is HIV negative
 PEP, if taken correctly, reduces the risk of HIV
infection by 80% 28
 Key Facts (2)
 ARVs taken for PEP are usually well tolerated
 Mild side-effects: Vomiting
 Severe side effects: Anaemia (stop PEP and go to clinic)
 Keep ARVs for PEP at maternity for 24-hour
access and at other well-advertised locations in
every facility
 Offer STI treatment and emergency
contraception, when indicated, for rape victims
accessing PEP
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Classification of risk

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 Immediate measures

 Remove infectious substance

 Wash exposed wounds and skin sites
thoroughly with soap and water
 Flush mucous membranes with water
 Do not use bleach, antiseptics or other
caustic substances

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Additional prevention measures
after risky sexual exposure
 Give emergency contraception within 72
hours if needed
 Repeat dose if vomiting occurs within 1 hour

 Explain: menstrual period should occur before

or around the expected time
 Consider giving presumptive STI treatment
 Use condoms throughout the period of PEP
until the final HIV test is done 6 weeks after
completion of PEP 32
 How to start PEP
 Start PEP as soon as possible – but no later
than 72 hours post-exposure
 However, still do HTC at baseline, at 3 and 6
months
 Explain dosage and importance of adherence
 Advise to return immediately if side effects
 Advise to practice safe sex
 Give 30 condoms and re-supply as requested
 Do not stop breastfeeding
 Write case details in PEP Register 33
 PEP follow-up

 At 30 days: completion of ARV prophylaxis;

 Assess adherence
 Give 60 condoms
 At 3 months: repeat HTS
 At 6 months: repeat HTS

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 Key Points

 PEP can reduce the risk of HIV transmission

by 80% after high risk exposure
 PEP must be started as soon as possible after
exposure
 It is ineffective to start PEP more than 72
hours post-exposure

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