The Morning After: Post-Exposure Prophylaxis

1. The Morning After:Post-Exposure Prophylaxis

2. Data Supporting Probable Efficacy of Non-Occupational PEP • Occupational exposure data • Mother-to-child data • Animal exposure data • Timing • Duration • Oral Exposure

3. Occupational Case Control Mother-to-Child Transmission Randomized controlled trial 81% reduction in healthcare workers ZDV versus no PEP 2/3 reduction in mother-to-child Pre- and intra-partum ZDV versus placebo Data Supporting Probable Efficacy of Non-Occupational PEP Cardo DM, et al. N Engl J Med 1997; 337:1485-90 MMWR Morb Mortal Wkly Rep 1996; 45:468-80

4. Mother-to-Child Transmission Retrospective chart review 81% reduction in healthcare workers ZDV versus no PEP 2/3 reduction in mother-to child Pre and intra-partum ZDV versus placebo Data Supporting Probable Efficacy of Non-Occupational PEP Cardo DM, et al. N Engl J Med 1997; 337:1485-90 MMWR Morb Mortal Wkly Rep 1996; 45:468-80

5. Relationship Between Time of Initiation of Therapy and Subsequent Infection Rate Wade NA, et al., N Engl J Med 1998; 339:1409-14

6. Use of PMEA with Intravenous SIV Use of tenofovir with IntravaginalHIV-2 24 hours is better than 48 or 72 hrs. Not effective after 72 hours 12 and 36 hours are effective 72 hours results in incomplete suppression (1 seroconversion) Relationship Between Timing of Animal Exposure Efficacy of PEP Tsai, CC, et al. J Virol 1998; 72:4265-73 Otten RA, et al. J Virol 2000; 74:9771-5

7. Use of PMEA with Intravenous SIV Use of tenofovir with newborn macaques given oral SIV 28 days was 100% protective 10 and 3 day exposure ineffective even 24 hours after exposure Combination pre- and post- exposure was effective Pre-exposure not effective Relationship Between Duration and Route of Animal Exposure Efficacy of PEP Tsai, CC, et al. J Virol 1998; 72:4265-73 Van Rompay, et al. AIDS Res Hum Retroviruses 1998; 14:761-73 Van Rompay ,et al. Aids 1998;12:F79-83 Van Rompay, et al., J Virol 2000; 74:1767-74

8. Timing Exposure types Within 72 hours Anal and vaginal intercourse Insertive and receptive Receptive oral intercourse with ejaculation Shared IDU Body fluid on mucous membrane/ broken skin When to Consider Post Exposure Prophylaxis Rolland, MM 2002

9. Source Known HIV infected Men who have sex with men (MSM) Injection drug use Anonymous Unknown risk factors When to Consider Post Exposure Prophylaxis Rolland, MM 2002

10. Medications Recommended: 2 nucleoside analogues Unknown importance of ZDV Consider protease inhibitor NVP is contraindicated Comprehensive Post Exposure Prophylaxis Program Rolland, MM 2002

11. Duration Follow-up HIV testing 28 days Baseline, 2-3 months, 6 months Consider adding 4-6 week and 12 months time points Comprehensive Post Exposure Prophylaxis Program Rolland, MM 2002

12. Other testing and interventions STD treatment and screening Hepatitis B and C screening Hepatitis A and B immunization Routine safety labs orper specific medications, history, and symptoms Comprehensive Post Exposure Prophylaxis Program Rolland, MM 2002

13. Comprehensive Post Exposure Prophylaxis Program • Counseling and referrals • Risk reduction counseling • Referrals for: • Substance abuse • Mental health Rolland, MM 2002