Post exposure Prophylaxis in HIV

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Post exposure Prophylaxis in HIV:

Post exposure Prophylaxis in HIV Dr. Nitin Solanki (M.D.) Assistant professor (Community Medicine) Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat

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Post exposure prophylaxis (PEP) refers to the comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens (HIV, HBV, HCV ).

Who is at Risk?:

Who is at Risk? Professionals with frequent blood exposures: Interns and medical students Nursing staff and students Physicians Surgeons Emergency care providers Dentists Labour and delivery room personnel Laboratory technicians Health facility cleaning staff and clinical waste handlers

Potentially infectious body fluids:

Potentially infectious body fluids Exposure to body fluids considered ‘at risk’ Exposure to body fluids considered ‘not at risk’ Exposure to body fluids considered ‘at risk’ Exposure to body fluids considered ‘not at Risk’ Blood Semen Vaginal secretions Cerebrospinal fluid Synovial, pleural, peritoneal, pericardial fluid Amniotic fluid Other body fluids contaminated with visible blood Tears Sweat Urine and faces Saliva Unless these secretions contain visible blood

Activities associated with needle stick injuries:

Activities associated with needle stick injuries

Steps for managing occupational exposure:

Steps for managing occupational exposure Wash wound and Surrounding skin with water and soap OR Irrigate exposed eye Immediately with water or normal saline OR Rinse the mouth thoroughly, using water or saline and spit again STEP-1: Manage exposure site Refer to physician

Steps for managing occupational exposure:

Do ‘s Do not’s Remove gloves, if appropriate Wash the exposed site thoroughly with running water Irrigate with water or saline if eyes or mouth have been exposed Wash the skin with soap and water Do not panic Do not put the pricked finger in mouth Do not squeeze the wound to bleed it Do not use bleach, chlorine, alcohol, betadine , iodine or other antiseptics/detergents on the wound Steps for managing occupational exposure

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Step 2: Establish eligibility for PEP Exposure within 72 hours Assess exposed individual Assess exposure source Assess type of exposure Determine risk of transmission Determine eligibility for PEP

Step 2: Establish eligibility for PEP:

Step 2: Establish eligibility for PEP Assessing the nature of exposure and risk of transmission Assessing the HIV status of the source of exposure

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Category Definition and example Mild exposure Mucous membrane/non-intact skin with small volumes E.g. : a superficial wound (erosion of the epidermis) with a plain or low calibre needle, or contact with the eyes or mucous membranes, subcutaneous injections following small-bore needles Moderate exposure Mucous membrane/non intact skin with large volumes OR percutaneous superficial exposure with solid needle E.g. : a cut or needle stick injury penetrating gloves Severe exposure Percutaneous with large volume e.g. : An accident with a high calibre needle (>18 G) visibly contaminated with blood; a deep wound (haemorrhagic wound and/or very painful); transmission of a significant volume of blood; an accident with material that has previously been used intravenously or intra-arterially.

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Source HIV Status Definition of risk in source HIV negative Source is not HIV infected but consider HBV and HCV Low risk HIV positive and clinically asymptomatic High risk HIV positive and clinically symptomatic (see WHO clinical staging) Unknown Status of the patient is unknown, and neither the patient nor his/her blood is available for testing (e.g. injury during medical waste management the source patient might be unknown). The risk assessment will be based only upon the exposure (HIV prevalence in the locality can be considered)

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Step 3: Counsel for PEP Provide information on HIV and PEP Obtain consent for PEP Offer special leave from work

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Step 4: Prescribe PEP Assess source patient’s ARV status Check for pregnancy if exposed female HCP Explain side effects of ARVs Explain post exposure measures against HBV and HBC

HIV Post-exposure Prophylaxis evaluation:

HIV Post-exposure Prophylaxis evaluation Exposure Status of source HIV+ and Asymptomatic Clinically symptomatic HIV status unknown Mild Consider 2-drug PEP Start 2- drug PEP Usually no PEP or consider 2-drug PEP Moderate Consider 2-drug PEP Consider 3-drug PEP Usually no PEP or consider 2-drug PEP Severe Consider 3-drug PEP Consider 3-drug PEP Usually no PEP or consider 2-drug PEP

PEP regimens to be prescribed by health centers:

PEP regimens to be prescribed by health centers Preferred Alternative 2-drug regimen (basic PEP regimen) 1st choice: Zidovudine (AZT) + Lamivudine (3TC) 2nd choice: Stavudine (d4T) + Lamivudine (3TC) 3-drug regimen (expanded PEP regimen) – consult expert opinion for starting 3rd drug(protease inhibitor) e.g Lopinavir / ritonavir (LPV/r) , Nelfinavir (NLF) or Indinavir (IND)

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STEP 5: Laboratory evaluation Provide HIV pretest counseling Draw blood to include CBC, liver function tests, pregnancy test, if applicable Provide HIV post-test counseling

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Step 6: Follow up and monitor adherence Record-keeping Follow up visits for clinical assessment at 2 weeks HIV test at 3 and 6 months

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