Non occupational HIV Exposure prophylaxis

1. Non occupational HIV Exposure prophylaxis Chief’s conference 2/6/14

2. Case 1 • 32 y/o healthy male p/w possible HIV exposure. Had receptive anal intercourse with new partner 2 days prior and condom broke. Does not know HIV status of partner and was a one night stand ( so partner will not agree to come in for testing). Patient’s last HIV test neg a month ago. STI screen neg also • Now what next?

3. How does Pep work? • Infection does not occur instantly after an exposure to HIV • The virus needs to spread throughout the body • This may take up to 3 days after the exposure • The “window of opportunity” for PEP • The brief period of time - after an exposure - where HIV has not yet spread throughout the body • During this time, PEP may be able to stop HIV from causing an infection

4. Post exposure prophylaxis (PEP)- steps involved • Assessment • Counseling • Prescription • Follow-up

5. Assessment of the risk of HIV transmission A. The nature of the exposure

6. B. The risk that the source is HIV positive, if their status is unknown • Source Person is Unavailable or Unwilling to Undergo HIV Testing : • initiate PEP and complete 28 day treatment • Source Person is Known to Be HIV-Infected : • information about his/her viral load, ARV hx, h/o ARV drug resistance should be obtained when possible to assist in the selection of an nPEP regimen; however, administration of the first dose of nPEP should not be delayed while awaiting this information • Source Person’s HIV Status Is Unknown and Source Is Available for Testing • obtain the most expeditious HIV test available (ideally with a turnaround time <1 hour), If the test results are not immediately available, the initiation of nPEP should not be delayed pending the test result. • If the source person’s HIV screening test result is neg : nPEP should be continued until results of the plasma HIV RNA assay are available: if the result is positive, the 28-day regimen should be completed; if the result is negative, PEP should be discontinued.

7. C. Information about the exposed person • most recent HIV test and result • potential exposures within the last 3 months (and earlier as indicated) • previous post-exposure prophylaxis and history of this treatment • evaluation of current STIs; hepatitis B and C infection • pregnancy risk, contraception and lactation, consider emergency contraception • medical history, all medications and drug allergies • psychiatric history • drug and alcohol history • Their knowledge of the source (if unavailable for interview) ***Provision of PEP should not be delayed whilst obtaining this information.

8. Post exposure prophylaxis (PEP)- steps involved • Assessment • Counseling • Prescription • Follow-up

9. Discuss the following issues with the patient and should document that they were discussed before initiating a regimen • Potential benefit, unproven efficacy, and potential toxicity of PEP • Duration of PEP regimen • Importance of adherence to the treatment regimen to prevent PEP failure or the development of drug resistance should infection occur • Need to reduce risk and prevent exposure to others • Clinical and laboratory monitoring and follow-up schedule • Signs and symptoms of acute HIV infection • How a full supply of medication will be obtained • Assess for emotional, psychological, and social factors that can contribute to risk behavior, such as depression, history of sexual abuse, and drug and alcohol use. • Refer patients to mental health and/or substance use programs when indicated and should consider the need for intensive risk-reduction counseling services

10. Post exposure prophylaxis (PEP)- steps involved • Assessment • Counseling • Prescription • Follow-up

11. Initiate ideally within 2 hrs, & up to 72hrs • Decisions regarding initiation beyond 36 hours should be made by the clinician in conjunction with the patient with the realization of diminished efficacy when timing of initiation is prolonged • No PEP if exposure >72hrs • Starter packs with a 3- to 5-day supply of medication should be available on-site for rapid initiation of treatment, and arrangements should be made for continuation of treatment. • Unlike protease inhibitors, which block HIV replication in steps after integration with cellular DNA, all three drugs in the recommended regimen act before viral integration with cellular DNA, providing a theoretical advantage in preventing establishment of HIV infection

13. Post exposure prophylaxis (PEP)- steps involved • Assessment • Counseling • Prescription • Follow-up

15. Case 2 • 24y/o healthy male presents for his annual physical. He reports he his in a monogamous relationship with another male. However, his partner was diagnosed of HIV a year ago and is currently on HAART. He inquires about prophylaxis for HIV • What next?

17. What is PrEP to prevent HIV infection? • The ongoing use of one or two antiretrovirals by HIV-negative individuals starting before an exposure and continuing afterwards • A potential option to prevent infection from ongoing exposures to HIV during periods of risk • A recently proven strategy still being studied

18. What’s involved in taking PrEP? • Assessment • Counseling • Prescription • Follow-up

19. Men who have sex with men (MSM) • Individuals who are in a sero discordant sexual relationship with a known HIV infected partner • Male to female and female to male transgender individuals engaging in high risk sexual behaviors • Individuals engaging in transactional sex • Injection drug users who share needles • Individuals who have been prescribed non occupational post exposure prophylaxis who demonstrate continued high risk behavior or have used multiple courses of nPEP

26. PEPline • The National Clinicians' Post-Exposure Prophylaxis Hotline • 1-888-448-4911 • 24 hours a day; 7 days a week • PEP Guidelines: http://www.nccc.ucsf.edu/hiv_clinical_resources/pep_guidelines/

27. References • http://www.hivguidelines.org/wp-content/uploads/2013/09/hiv-prophylaxis-following-non-occupational-exposure.pdf • http://www.cdc.gov/hiv/prevention/research/index.html?s_cid=tw_c-nchhstp-nhtd-036 • http://www.ashm.org.au/default2.asp?active_page_id=251

28. Thank you for not having questions