Transcript NPEP - Melbourne Sexual Health Centre

Non-Occupational Post Exposure Prophylaxis
NPEP
Jude Armishaw
Victorian NPEP Service
The Alfred
What is PEP?
• Post-exposure prophylaxis (PEP)
– A treatment following an exposure to an infection
– Aim is to prevent the infection from becoming
established in the host
• HIV PEP
– Use of antiretroviral medications to reduce the risk
of transmission of HIV
– Same drugs as used to treat HIV infection
– Started with 72 hours of exposure
– Taken for one month (28 days)
NPEP
• Non occupational post-exposure prophylaxis
– Use of PEP outside the healthcare setting
– Sexual exposure
– Injecting drug use exposure
HIV Transmission Risk
=
RISK CARRIED BY THE EXPOSURE
X
RISK THAT THE SOURCE IS HIV POSITIVE
Risk of HIV Transmission - Source HIV Positive
EXPOSURE ROUTE
SOURCE HIV INFECTED
Estimated per act risk
Receptive anal intercourse
1/120
Needle sharing injecting drug use
1/150
Occupational needlestick injury
1/333
Insertive anal intercourse
1/1000
Receptive and insertive vaginal
intercourse
1/1000
Receptive oral intercourse with
ejaculation
Not measurable
Insertive oral intercourse
Not measurable
HIV Transmission Risk
• Risk estimates only
• HIV transmission heterogeneous
• Per-contact risk for any individual may be considerably
higher than the average
• More useful for assessing population based risk rather
than absolute risk for an individual
Cofactors increasing HIV transmission
• High plasma viral load in the source partner
• Presence of STI, especially genital ulcer disease and
symptomatic gonorrhoea in source or exposed person
Source ~ increases viral load
Exposed ~ increases dendritic cells
• A breach in mucosal integrity of exposed person (e.g. scratch,
cut) through which host dendritic cells capture HIV
Role of dendritic cells in HIV transmission
What is the risk where the partner’s HIV status is unknown?
• Most common presentation for NPEP is MSM following
unprotected anal sex with an anonymous partner
• How do we assess risk where source HIV status
unknown?
• Seroprevalence
HIV Transmission Risk
=
RISK CARRIED BY THE EXPOSURE
X
RISK THAT THE SOURCE IS HIV POSITIVE
HIV Sero-prevalence
Community Group
HIV Seroprevalence
MSM – Melbourne
10% ( Gay Periodic survey)
Injecting Drug users
–MSM
–All others
Up to 32% (may vary locally)
1%
Heterosexuals
–Blood donors
–STI clinic attendees
–Commercial sex workers
0.0005%
<0.2%
0.1%
Selected other regions
–Oceania, W & central Europe, N Africa &
Middle East, E Asia, NZ
–Latin America, N America, S & SE Asia, E
Europe & Central Asia
–Caribbean
–Sub-Saharan Africa
≤0.4%
0.3-0.9%
1.0%
5.0%
HIV Transmission Risk & Recommendations
ESTIMATED PER ACT RISK
EXPOSURE ROUTE
Source HIV +
Source
unknown
Source
unknown
MSM
Heterosexual
Receptive anal intercourse
1/120 R3
1/1 200 R2
1/120 000
Needle sharing IDU
1/150 R3
1/880 R2
1/15,000 C2
Insertive anal intercourse
1/1000 R3
1/10,000 C2*
1/1 000 000
STI, trauma blood
Receptive vaginal
intercourse
1/1000 R3
1/1 000 000*
Insertive vaginal
intercourse
1/1000 R3
1/1 000 000*
Receptive oral intercourse
with ejaculation
Not measurable
C2*
Not
measurable
Not
measurable
Not
measurable
Not
measurable
oral mucosa not intact
Insertive oral intercourse
Not measurable
Efficacy and evidence
Animal data
• Start within 72 hours of exposure
• Sooner the better
• Taken for 28 days
• Completion of course with good compliance
HCW case control study and MTC
• Reduces HIV transmission by up to 80%
Recommended NPEP Regimens
2- drug regimen
Truvada
(Tenofovir 300mg/Emtricitabine 200mg)
One tablet daily for 28 days
Or
Combivir
(Zidovudine 300mg/Lamivudine 150mg)
One tablet twice daily for 28 days
3- drug regimen
One of the above 2 drug combinations
Plus
Kaletra
(Lopinavir 200mg/Ritonavir 50mg)
Two tablets twice daily for 28 days
Addition of 3rd drug
• Higher risks (RAI, IAI, RVI, IVI, IDU w pos source)
– But … no data to show 3 drug NPEP regimen more
efficacious than 2 drug regimen
– Based on evidence that 3 drugs is more effective in
treating established HIV (HAART)
• Source ARV Hx
– Where resistance genotype indicates drug
resistance tailor NPEP regimen
Side effects
• Side effects in 45-75% NPEP patients
– Nausea
– Headache
– Fatigue & lethargy
– Diarrhoea
• Adherence to full 28 day course important
• Completing a 2 drug regimen may exceed the benefit of a
poorly tolerated 3 drug regimen
NPEP Service
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Service commenced Aug 2005
Alfred Hospital, VAC and DHS
Hub and Spoke Model
Hub is Alfred Hospital
– 0.8 FTE Clinical Nurse Consultant (CNC)
– 0.3 I.D. Physician
– 0.3 Clinical Psychologist
– 5 Registered Nurses on-call 24/7 for 1800 number
NPEP
spoke clinics in Metropolitan
Metropolitan
Rural
& Clinic
Rural Vic• Bendigo
– Prahran Market
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Centre Clinic
Carlton Clinic
MSHC
Northside Clinic
Recreation Medical
Centre
Alfred ED (A/H only)
The Alfred ID Clinic
Middle Park Clinic
Richmond Hill Medical
Centre
Monash Medical Centre
Royal Melbourne
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Shepparton
Geelong
Wodonga
Warrnambool
Telephone Information Line
1800 889 887
(24 hours Fri – Mon and 0830 to midnight
Tue – Thurs)
• Staffed by RNs on rotating roster
• RNs trained in
– HIV
– Sexual Health
– NPEP
– Telephone Counselling Skills
Community exposure to HIV
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Call 1800 889 887
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Nurse assess and refer to spoke clinic if need NPEP
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Patient go to spoke clinic
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Given starter pack (7 days)
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Paperwork faxed to NPEP Service and remainder packs
sent to clinic for patient to collect
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Patient return at week 1 for remaining 21 days medication
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Patient return for week 4 and 12 follow-up
Case 1
A young man tells you that he was in a sauna last night and had insertive
anal sex with an anonymous partner. He did not use a condom.
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What is his risk of getting HIV from this exposure?
What factors need to be assessed?
Is NPEP recommended?
Case 2
A heterosexual man tells you that he went to see a female sex worker
in Melbourne yesterday and had insertive penile-vaginal sex. He used
a condom, but when he withdrew he noticed that the condom had
broken.
> What is his risk of getting HIV from this exposure?
> Would you recommend that he take NPEP?
> Would the risk be any different if it had happened in Thailand?
Case 3
A woman tells you she was walking along St Kilda beach and felt a sharp
sting in her foot. When she looked down she saw that she had stepped on
a needle.
> What is the risk of getting HIV from this exposure?
> Is NPEP recommended?
> What are the other factors that need to be assessed?
Case 4
A man tells you that he had unprotected receptive anal sex 2 days ago
with a casual partner that he met on the internet. Last night this partner
told him that he has HIV.
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What is his risk of getting HIV from this exposure?
Is NPEP recommended?
What other factors would you need to assess?
Case 5
A young man is very distressed that he had unprotected receptive oral sex
last night with an anonymous partner that he met at a bar. The partner
ejaculated into his mouth.
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What is the risk of HIV from this exposure?
Is NPEP recommended?
What other factors would you need to assess?
Feedback
Final Questions and Thankyou