Issues around HIV & post-exposure prophylaxis

1. Issues around HIV & post-exposure prophylaxis Dr. Laura Sauve Oak Tree Clinic Pre-departure training June 2014

2. What are the risks if I get a needle stick / blood exposure to mucous membranes? • HIV • Hepatitis B – vaccine preventable!!! • Hepatitis C For further details see: http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure

3. Hepatitis B • Transmission: vertical, sexual, via needles / blood (much more easily transmissible than HIV) • ~2 billion people infected world wide • ~240 million chronic infections • Vaccine preventable! • So, you shouldn’t be working as a health care worker if you are not vaccinated • Make sure you have protective titres before leaving

5. Hepatitis C • Transmitted principally via needles / blood – unsafe medical equipment, IDU • Uncommon in children, generally • Highest prevalence countries – adult prevalence est • Egypt (22%), Pakistan (4.8%) and China (3.2%) • Less common in Sub-Saharan Africa (1.5-3.5% estimated) • Not vaccine preventable, no PEP

6. ~3.3 million HIV infected children world wide

7. Most infections in sub-Saharan Africa New Infections Source: Towards an AIDS-Free Generation: UNICEF Stocktaking report

8. HIV Epidemiology in Children • South Africa: • All Children 2-15, seroprevalence survey - 2.5% (95% CI:1.9 – 3.5%) (Source: http://www.childrencount.ci.org.za/indicator.php?id=5&indicator=29) • Western Cape adults ~18% • Red Cross Hospital inpatients, one day cross sectional survey ~18% (S Afr Med J. 2006 Sep;96(9 Pt 2):993-5.) • Bangladesh: • Adult HIV prevalence <0.1%; no estimate for children (UNICEF) • BIPAI Clinics (all countries): • Virtually 100% of outpatients • Uganda • ~150,000 HIV infected children (UNICEF)

9. Risk of HIV transmission after a significant exposure (source known HIV infected) • Percutaneous exposure risk 0.3% (1 in 300). • Mucocutaneous exposure risk 0.1% (1 in 1,000). • Factors which increase the risk of HIV transmission include: • High viral load • Visible blood on the device and/or a device previously in a source’s artery or vein • Depth of wound • Volume of blood • Gauge of needle in needlestick exposures (larger bore needles carry greater risk because of the larger volume of blood exposure). For further details see: http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure

10. What is a “significant exposure” • Patient KNOWN to be HIV positive or high risk* • PLUS • Any percutaneous exposure to infectious body, fluids • Mucous membrane or non-intact skin, exposure, i.e. more than a few drops of blood and/or duration of exposure of several minutes or more. * All inpatients in the Western Cape & generally in Subsaharan-Africa who are not already known to be HIV negative are “high risk”; adolescents may be in the “window period” so even if recently tested are “high risk”

11. Cases where there is a negligible risk of transmission • Source known to be HIV negative OR • HIV infected source with • Minor percutaneous, mucous membrane or skin exposure to non-infectious body fluid. • Intact skin exposure to a small quantity of blood (less than three drops) or fluid visibly contaminated with blood of short duration i.e. less than three minutes.* • Bites unless there has clearly been transmission of infected blood. • A superficial scratch which does not bleed. • Injuries received in fights would rarely be appropriate indications for prophylaxis unless it is clear that transfer of infected blood has occurred. No PEP recommended

12. What if source was thought to be high risk but status not known? • Assume they are infected; HIV serology should be done (with parental consent) • Check local protocols (ideally prior to a needle stick!) • “High Risk”: • All inpatients in the Western Cape & generally in Subsaharan-Africa who are not already known to be HIV negative • Adolescents; they may be in the “window period” so even if recently tested negative are “high risk”

13. What is PEP & the side effects • Tenofovir: 1 tab (300 mg) once a day for 28 days • well tolerated and side effects are mild. They may include nausea, diarrhea and gas. • Rarely, liver or kidney changes. • Lamivudine (3tc): 1 tablet (150 mg) twice a day for 28 days • usually well tolerated in short-term therapy and side effects are rare. Reversible decreased white blood cell count is the commonest side effect. • Tingling of the hands and feet (peripheral neuropathy) is very unlikely to occur with one month of treatment. • Kaletra: two tablets twice a day with meals for 28 days • Side effects include diarrhea, nausea, vomiting and abdominal pain. • Occasionally there will be changes in liver function tests. Kaletra may interact with a wide number of medications.

14. What do I have to consider before starting PEP after an exposure? • Toxicity – drugs often not well tolerated by health care workers on PEP. • Need to start ASAP – ideally within 2 hours of exposure • Many drug interactions if there are any other medications

15. Why take PEP: • HIV infection is lifelong and has major health implications. • Markedly reduce the risk of transmission of HIV • ARVs taken for one month have few long-term side effects despite significant short term morbidity. • If ARVs are taken and HIV infection still occurs, the early use of antiretrovirals may favourably alter the course of subsequent infection.

16. Summary: Prevention! • Discuss with your preceptor before it happens – what to do in that hospital • Most important: Try to avoid a needlestick or splash!!! • Careful use of universal precautions • Gloves • Eye protection • Careful needle disposal

17. Summary: if a needlestick arises • First aid – wash with lots of water & soap • Discuss with your preceptor • If in South Africa, consider discussing with an expert in HIV / occupational exposures. • Contact program director urgently • Serology on source & yourself (HIV, Hep B, Hep C) • If high risk percutaneous injury & presumed HIV infected source, start PEP • If lower risk setting, consider PEP.

18. If you want to take PEP with you • Costs… • 5 day PEP starter kit ~$250 • 1 month PEP ~$1000 • Could consider buying a kit & if unused, passing it on to the next resident • Ask your on site supervisor if PEP is available in your elective site for purchase • Discuss with your travel health physician and consider discussing with Center for Excellence in HIV / AIDS pharmacy staff: 1-888-511-6222

19. Center for Excellence in HIV / AIDS • Clinical guidelines: http://cfenet.ubc.ca/therapeutic-guidelines/accidental-exposure • CFE Pharmacy: 1-888-511-6222