Transcript Education material on Post-Exposure-Prophylaxis

BORDERNETwork
Training on
Post-Exposure-Prophylaxis
Dr. med. Wolfgang Güthoff /
Alexander Leffers, M.A.
www.bordernet.eu
www.aidshilfe-potsdam.de
This presentation arises from the
BORDERNETwork project which
has received funding from the
European Union, in the framework
of the Health Program, and cofunding
of
the
Ministry
of
Environment,
Health
and
Consumer
Protection
of
the
Federal State of Brandenburg. The
sole responsibility of any use that may
be made of the information lies with the
authors (SPI, AIDS-Hilfe Potsdam e.V.)
Table of Contents
Transmission
Conditions for PEP
Guidelines on PEP
Blood Control
Problems with PEP
PEP HIV - Exposure
When?
 Injury with HIV contaminated instruments
 Wetting of open wounds and mucosa with HIV
contaminated fluids
 Unprotected sex with an HIV infected person
 Use of HIV contaminated needles (needle sharing)
 Transfusion of HIV contaminated blood or blood products
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
PEP - Guidelines
 The ultimate goal of PEP is:
• to suppress any viral replication that
may occur,
• to shift the biological advantage to the
host cellular immune system to prevent
or abort early infection
http://www.who.int/hiv/pub/guidelines/PEP/en/
http://www.hivguidelines.org/wpcontent/uploads/2009/05/pep_card.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.ht
m
Occupational PEP Probability
of Transmission
Factors influencing transmission:
 Kind of transmitting material
(Viral concentration is highest in the blood)
 Kind of exposure:
• Hollow needle
• Cut injury
• Open wound
• Exposure of mucosa
 Viral concentration from index person
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Occupational PEP Probability
of Transmission
Average risk:
 Percutaneous
0.3%
 Mucous membrane
0.1%
 Non-intact skin
<0.1%
 Blood transmission
100%
(non occupational course – unprotected sex
0,03 – 7,5%)
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Risk for an HIV-Transmission depending on
Exposure in Relation to Average Risk
Kind of Exposure
Exposition Risk in Relation to
Average Risk
Very deep injury
16 : 1
Visible blood at instrument
5:1
Index person has high viral load
6:1
Exposure of mucosa
1 : 10
Exposure of damaged skin
1 : 10
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Occupational PEP Probability
of Transmission
 High Risk
• deep parenteral inoculation via hollow needle
• parenteral inoculation with high viral titers
 Less Risk
• injuries via non-hollow needle
• mucosal exposure/non-intact skin exposure
 Risk not identified
• intact skin exposure
• exposure to urine, saliva, tears, sweat
Exposure Risk
 Little information on efficacy of PEP in humans
 Seroconversion infrequent following occupational exposure to HIV-
infected blood
 Use of Zidovudine (ZDV) was associated with an 81% decrease in
the risk for HIV infection
• limitations include a small number of cases, and that cases
and controls came from different cohorts (Cardo et al, NEJM
1997;337:1485-90.)
PEP - Conditions
 contact with relevant risk of transmission between an HIV-negative
Person and an HIV- infected Person (Index person)
 Negative HIV-Test in exposed Person is a condition for PEP
 HIV- Rapid Test of Index person
• HIV Rapid Test available?
PEP - Counselling and Decision
(two physicians should get knowledge and experience in this field in every hospital)
 Estimation of risk
 Decision for PEP:
•
•
•
•
strongly encourage
recommend
offer
do nothing (counselling is important that the exposed person is assured)
 Counselling for PEP encloses:
•
•
•
•
no blood donation for 12 month
safer sex until getting final HIV test after six month
drugs do not have an apply for this indication
written confirmation
Occupational PEP
Immediate Measures
 Measurements at cut injuries or needle sticks
• disinfection, wash it with soap and water
 Mucosa membrane exposure
• Douche of oral cavity with 70% alcohol: mouth wash 5
times for 15 seconds
Douche of eyes with running water
 Non intact skin
• Wash with soap, water and antiseptic
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Post exposure Prophylaxis (PEP)
PEP after occupational HIV-Exposition
 Transdermal injury with contaminated
hollow needle

 Superficial injury
(f. e. with surgery needle)

strongly encourage
 Contact of damaged skin with blood 
offer
 Contamination of intact skin
 Contamination of mucosa
membrane with blood
 Contamination of mucosa
membrane with urine or saliva
offer

do not recommend

recommend

do not recommend
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
PEP – when to start and time limits
Replication
HIV and
andTargets
Targetsofof
Therapy
Replication of
of HIV
Therapy
HIV
HIV
CD4 - cell
 Entry and Fusion
2h
 DNA-Integration in nucleus
12h
 Viral replication after another 12h
HIV
HIV- entry
und Fusion
HIV
Protease
Reverse Transkriptase
 PEP within 24h (best - start within
first 2h)
Integrase
 >72h after Exposition: PEP is not
practical
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Medications for PEP
(German – Austrian Guidelines)
Tenofovir 300mg
plus
Emtricitabin 200mg
Kaletra (Lopinavir + Ritonavir)
2 x 400/100mg
combined
with
or
as combination product
(Truvada 1x1 pill)
Sustiva 1 x 600mg
Alternative:
Alternative:
Invirase (2 x 1000mg plus
Ritonavir 2 x 100mg)
Combivir 2 x 1 pill
(Zidovudin + Lamivudin)
or
Fosamprenavir
Indinavir
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
European Guidelines
 HIV- rapid test from Index person
 If Index person’s HIV-RNA > 1000 copies/ml – testing of drug
resistance
 Start PEP if possible within 4h and not later then 48h
 Duration: 4 weeks
 Medication:
• Truvada (TDF/FTC)
1 x 1 pill
Alternative: Combivir (ZDV/3TC)
+
• Kaletra (LPVr)
2 x 1 pill
2 x 2 pills
Alternative: Invirase 500(SQV) 2 x2 capsules
and Norvir (RTV) 2 x 100mg
Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V. und der Österreichischen AIDSGesellschaft (ÖAG) et al., in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.
Blood Controls
Serologic control (HIV, possible HBV, HCV):
 at the start
 after 6 weeks,
 after 3 month
 after 6 month
Laboratory tests:
 at the start, after 2 weeks and after 4 weeks:
Blood count, liver enzymes, kidney function,
blood sugar, urine
Problems regarding HIV – PEP
Pregnancy and lactation period
 No substance is harmless!
 PEP only at high risk
 Experience only with Retrovir and Epivir
 Sustiva (Efavirenz) is contraindicated!
Problems regarding HIV – PEP
 Period between exposition and starting PEP not longer
than 24 h
Problems regarding HIV – PEP
 High risk through massive inoculation of
infections material
Problems regarding HIV – PEP
 Strong side effects of HAART
(mental – Efavirenz)
Problems regarding HIV – PEP
 Index person gets HAART and
drug resistance is probable
• Course of CD4 cells
• Opportunistic infections (OI)
PEP - Index person
 HIV-Infection known?
 How fast is an HIV-test possible?
 HIV- rapid tests every time for every physician
available?
Treatment Algorithm
Did an exposure to a potentially
HIV-infected fluid occur?
NO
YES
Did a significant risk of
transmission of HIV occur?
(Contact of a HIV negative person with
an HIV positive person (index
person/source patient)
NO
• No indication of
PEP
• No follow-up
needed
Stop PEP
•
•
YES
Is the patient presenting within
ideally 2 hours, not later than 72
hours of the exposure?
• No indication of
PEP
• No follow-up
needed
NO
• PEP not
indicated
• Follow-up
• HIV testing
YES
Serological
test of
source
patient is
confirmed
HIV negative
no evidence
of acute
retroviral
syndrome
Continue PEP for
4 weeks
•
•
•
Serological test of
source patient is
confirmed HIV
positive
Evidence of acute
retroviral
syndrome occurs
Source patient is
unknown,
unwilling etc.
Initiation of PEP regimen:
•
•
PEP within 24h
(best - start within first 2h)
HIV monitoring
Can the source patient be interviewed?
If yes: interview on HIV status or infection risk, resp. test/rapid test on HIV
If yes: Individual
benefit-risk assessment
If no: belongs the source patient to a high risk group (with high prevalence)
If no: PEP not indicated
Adopted from: New York State Department of Health/ AIDS Institute: Recommendations for HIV Postexposure Prophylaxis (PEP)
URL: http://www.hivguidelines.org/wp-content/uploads/2009/05/pep_card.pdf
Adopted from: Postexpositionelle Prophylaxe der HIV-Infektion. Gemeinsame Empfehlung der Deutschen AIDS-Gesellschaft (DAIG e.V.)
und der Österreichischen AIDS-Gesellschaft (ÖAG) et al. in: Dtsch Med. Wochenschr 2009; 134: S 16-S 33.