Occupational HIV Exposure Prophylaxis

1. Occupational HIV Exposure Prophylaxis Dr Truong Anh Tan June 30th , 2010

2. Infected post-exposure rate/1000 • Blood infusion 900 • IDU (shared needle) 6,7 • Anal sex receiver 5,0 • Needlestick 3,0 • Vaginal sex female 1,0 • Anal sex giver 0,65 • Vaginal sex male 0,5 • Oral sex receiver 0,1 • Oral sex giver 0,05

3. Estimated Pathogen-Specific Seroconversion Rate Per Exposure for Occupational Needlestick Injury . AETC http://depts.washington.edu/hivaids

4. Type of Exposure Way Involved in Transmission of HIV to Health Care Workers AETC http://depts.washington.edu/hivaids

5. Source of HIV Involved in HIV Transmission to Health Care Worker AETC http://depts.washington.edu/hivaids

6. Risk Factors for HIV Transmission with Occupational Exposure to HIV-Infected Blood

7. Other Possible Risk Factors Hollow bore vs solid bore No documented cases to date of seroconversion from suture needles Glove use 50% decrease in volume of blood transmitted Mucous membrane exposure Mosquitoes bite?

8. Standard Precautions Definition Standards developed to prevent exposure and transmission of disease in occupational setting Provide guidance for the safe handling of infectious material

9. Components of Standard Precautions Hand washing Use protective barriers when indicated Gloves: mucus membranes, body fluids, broken skin Goggles: procedures Masks: procedures

10. Components of Standard Precautions (2) Sharps and waste - handle with gloves and dispose in designated containers Needles Scalpels Suture material Bandages Dressings Anything contaminated with any body fluid

11. Handling with Disposing Sharps Do not recap needles! Put containers within arms reach Use adequate light source when treating patients Wear heavy-duty gloves when transporting sharps Incinerate used needles to a sufficient temperature to melt Keep sharps out of reach of children

12. Components of Standard Precautions (3) Re-usable instruments  must be thoroughly disinfected Speculums Surgical tools Thermometers Immunizations for Healthcare Workers Hepatitis A and B

13. Recommended Antiseptic Solutions Alcohol 70% Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub) Iodine 3% Iodophores 7.5-10% (e.g. Betadine)

14. Recommended Disinfectants Chlorine, 0.5% (Barkina) Sedex and Ghion brands contain 5% Chlorine, dilute for use Glutaraldehyde, 2-4% (e.g. Cidex) Formaldehyde, 8% Hydrogen peroxide, 6% Soak the instrument for 20 minutes after decontamination and cleaning

15. Management of Occupational Exposure • HIV AB: for both (giver and receiver) • Hepatitis : B & C • CBC • SGOT/SGPT • Blood Glucose •  136th month

16. Diagnostic Testing 1 mil 100,000 + HIV RNA HIV-1 Antibodies _ 10,000 Ab 1,000 HIV RNA Exposure 100 Symptoms 10 0 14 21 28 7 Days Image courtesy of The Center for AIDS Information & Advocacy, www.centerforaids.org

17. The Early Stages of HIV Infection Cell free HIV T-cell Immature Dendritic cell PEP Skin or mucosa Via lymphatics or circulation Burst of HIV replication 24 hours 48 hours HIV co-receptors, CD4 + chemokine receptor CC5 Mature Dendritic cell in regional LN undergoes a single replication, which transfers HIV toT-cell • Selective of macrophage-tropic HIV

19. Wound Care Gently wash wounds with soap and water/ 5 minutes  alchol 70% 5 minutes (don’t scrub vigorously) Allow wounds to bleed freely Irrigate exposed mucosal surfaces with sterile saline

20. Post Exposure Prophylaxis (PEP) Definition: Use of therapeutic agent to prevent establishment of infection following exposure either occupationally or non-occupationally to pathogen Roles in Occupational Exposure: HIV prevention HBV prevention  Tests before ARVs therapy

21. Step 1: Does This Patient Need HIV PEP? Source patient Unknown / Unwilling to get tested* HIV - HIV + High back-ground risk Low back-ground risk No PEP PEP No PEP *CDC recom: usually PEP unnecessary; consider use if source patient is high risk

22. Step 2: Determine HIV Status Code of Source (HIV SC) HIV Negative HIV Positive Asymptomatic/high CD4 = HIV SC 1 Advanced disease,primary infection or low CD4 =HIV SC 2 HIV Status Unknown or Source Unknown = HIV SC Unknown No PEP No PEP or + PEP with 2 drugs PEP

23. CDC Sep 2005

25. Occupational HIV PEP 2 drug regimen Zidovudine plus lamivudine (combivir) Stavudine plus Lamivudine Tenofovir plus lamivudine 3 drug regimen LPV/r or Indinivr or Nelfinavir plus NRTI backbone Efavirez plus NRTI backbone Consider resistance potential of source patient Don’t use NVP (hepatotoxic) When to start  ASAP PEP no efficacy after 72 hours

26. PEP Guideline from MOH -PEP 1: AZT + 3TC AZT: 300mg bid & 3TC: 150 mg bid. -  PEP 2: 3TC + d4T 3TC: 150mg bid & d4T: 30-40mg bid. < 60 kg, d4T: 30 mg bid. > 60 kg, d4T: 40 mg bid. AZT(Zidovudine);3TC(Lamivudine);D4T(Stavudine)

27. Advanced PEP(for high risk) PEP 1 or 2 plus 1of following agents: - NFV: 1,25 g bid. - EFV: 300 mg bid - LPV/r: 500 mg bid (recommended)  28 days duration (MOH guideline for PEP updated on 9/2009)

28. -CDC: HIV Ab at 6th week, 3rd month, 6th month -Extended HIV Ab testing at 12 months recommended if a source patient co-infected HCV VL testing not recommended unless Primary HIV Infection (PHI) suspected -Early diagnosis: HIV RNA PCR at 3th week Follow-up HIV Testing MMWR June 29, 2001 / 50(RR11);1-42.

29. Thank you for your attention!