4th Year Student Electives overseas HIV and Post-Exposure Prophylaxis

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4th Year Student Electives overseas HIV and
Post-Exposure Prophylaxis

• Dr Eric Monteiro
• Clinical Director
• Department of Genitourinary Medicine

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Prevention

• The most effective approach is not to put
  yourself at risk at all!!
• Use good infection control procedures at all
  times
• Wear gloves if you are likely to be contaminated
  with body fluids (take gloves with you)
• Think about what you will do in the event of an
  injury before it happens

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Main issues discussed

• Sero-prevalence of HIV in the local population
• Risks of HIV from occupational contamination
  injuries and risk assessment
• What immediate action to take in the event of an
  occupational injury
• Recommendations for PEP
• Questions you should ask

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Adults and children estimated to be living with
HIV as of end 2005 (WHO)
Eastern Europe Central Asia 1.6 million 990
000 2.3 million
Western Central Europe 720 000 570 000 890
000
North America 1.2 million 650 000 1.8 million
East Asia 870 000 440 000 1.4 million
North Africa Middle East 510 000 230 000 1.4
million
Caribbean 300 000 200 000 510 000
South South-East Asia 7.4 million 4.5 11.0
million
Sub-Saharan Africa 25.8 million 23.8 28.9
million
Latin America 1.8 million 1.4 2.4 million
Oceania 74 000 45 000 120 000
Total 40.3 (36.7 45.3) million
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Epidemiology of HIV world-wide - local
seroprevalence

• Highest in sub Saharan Africa
• Highest in Central, East, South East and South
  Africa
• Up to 20 of the population HIV infected
  (Botswana 36)
• Far East - Thailand (2) and Cambodia(4),
  Caribbean (1-5).
• Increasing in India, Eastern Europe and Russia

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Risk after exposure

• Risk of acquiring HIV infection following
  occupational exposure to HIV infected blood is
  low.
• Average risk for HIV transmission after
  percutaneous exposure to HIV infected blood in
  healthcare settings is approx 1 per 300
• After mucocutaneous exposure, lt1 in 1000.
• No risk of transmission where intact skin is
  exposed to HIV infected blood

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Calculating HIV seroconversion risk after
needlestick/sharps injury

• Known HIV. Risk is 1 in 300
• HIV serostatus unknown - where prevalence of HIV
  in local/hospital population is
• 1 in 3 (ie 30). Risk is 300 x 3 1 in 900
• 1 in 10 (ie 10). Risk is 300 x10 1 in 3000
• 1 in 100 (ie 1). Risk is 300 x 100 1 in 30,000
  

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PEP occupational exposure

• Four factors associated with an increased risk of
  occupationally acquired HIV infection
• Deep injury
• Visible blood on the device which caused the
  injury
• Injury with a needle from artery or vein
• Terminal HIV illness in source patient
• Almost all reported cases of HIV seroconversion
  have occurred after injuries with hollow bore
  needles.

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Body fluids and materials which may pose a risk
of HIV transmission

• Amniotic fluid
• Cerebrospinal fluid
• Human breast milk
• Pericardial fluid
• Peritoneal fluid
• Pleural fluid
• Saliva in association with dentistry
• Synovial fluid

• Unfixed human tissues and organs
• Vaginal secretions
• Semen
• Any other fluid if visibly bloodstained
• Fluid from burns or skin lesions

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Immediate action following a contamination
incident

• Wound or non-intact skin to be washed liberally
  with soap and water without scrubbing
• Antiseptics should not be used as no evidence of
  efficacy and effect on local defences unknown
• Free bleeding encouraged
• If mucous membranes contaminated - irrigate with
  water and remove contact lenses

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Overall management of the injury

• Seek the advice of an experienced Health Care
  worker to manage the incident.
• You should know who this person is before you
  start your elective discuss with your local
  supervisor.

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Risk Assessment of Occupational Exposure

• Ideally this should not be done by the injured
  Health care Worker
• Assessment of the injury involves
• Nature of the injury - was there significant
  contamination?
• The risk the patient has HIV (Hep C,Hep B)
• Known HIV
• Person of unknown HIV serostatus

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Risk Assessment (2)

• Circumstances of exposure
• Assess if exposure was significant
• Types of exposure with contaminated
  instruments/body fluids associated with
  significant risk
• Percutaneous injury (needles, instruments, bites
  which break skin)
• Exposure of broken skin (abrasions, cuts)
• Exposure of mucous membranes inc. the eye, mouth

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Risk Assessment (3)

• The Source Patient
• If of unknown HIV serostatus - A designated
  doctor should approach the source patient and ask
  for informed agreement to HIV testing (This
  should not be the exposed worker)

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Current guidelines for UK Health care workers
seconded overseas

• HIV post-exposure prophylaxis Guidance from the
  UK Chief Medical Officers Expert Advisory Group
  on AIDS. UK Department of Health. February 2004.
  (currently under revision)
• http//www.dh.gov.uk/assetRoot/04/08/36/40/0408364
  0.pdf

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HIV PEP

• Current EAGA recommendations for UK Health care
  workers seconded overseas
• In areas where no antiHIV treatment is available
  for patients
• 2 Drug combination
• Zidovudine 250mg and Lamivudine 150mg bd
  (Combivir 1 tablet bd) for 28 days

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HIV PEP

• BUT
• AntiHIV treatment is being rolled out to the
  local population in many developing countries
  (parts of Uganda, Malawi, Botswana etc)
• In these areas anti-HIV treatments are likely to
  be readily available to staff who have
  significant occupational injuries (ask your
  supervisor!)
• Drug resistant HIV likely to be present in local
  population
• 3 Drug combination recommended for exposures to
  treatment experienced HIV population
• Zidovudine 250mg Lamivudine 150mg bd (Combivir
  1 tablet bd) Kaletra 2 tablets bd for 28 days
• PEP should ideally be started within 1 hour of
  the injury

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Costs

• Combivir 1 bd
• 7 days 78.96
• 28 days 315.84
• Combivir 1 bd Kaletra 2 tablets bd
• 7 days 176.45
• 28 days 709.63
• Recommend 7 day pack

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WARNING

• The sale of anti HIV drugs, as with any
  prescription drugs, to a third party is illegal,
  may result in criminal prosecution and
  proceedings by the General Medical Council.
• Disposal of unused supplies of antiHIV drugs are
  recommended on your return to the UK after your
  elective. This can be arranged through any
  pharmacy.
• It is unsafe to purchase or use any drug
  prescribed for another person

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Nelfinavir

• This agent was previously recommended and
  prescribed as HIV PEP
• In the last month it has been withdrawn by the
  Roche Pharmaceuticals as some UK supplies have
  been contaminated with a carcinogen.
• Please hand any supplies of this drug that you
  have to any pharmacy for disposal.

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Questions that you need to answer

• Will any work during my elective put me at
  significant risk of contamination with blood
  borne viruses? - if the answer is no, you do not
  need to consider PEP.
• What is the prevalence of HIV in the
  local/hospital population?
• If high, is the local population being treated
  with antiHIV treatments?

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• What is the local process for handling
  significant exposures/contamination injuries?
• Are antiretrovirals locally available within the
  hospital/health care centre where you are
  working? If so, which ones, how quickly can they
  be accessed and what do they cost?
• Who will manage/advise you locally in the event
  of a contamination injury?
• Contact your local supervisor for information
  (although you often dont get a response!)
• Consider insurance to cover repatriation in event
  of significant injury requiring PEP.

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Sources of local information about PEP and
prescriptions

• Undergraduate office
• Department of Genitourinary Medicine LGI (or ID
  department SJH)
• Private Prescriptions available late May/June
  from GUM
• Advice on PEP available from GUM Consultant/SpR
  24/7 (Office hours 0113 3926762, out of hours LGI
  switchboard 0113 2432799)
• Follow up advice/drugs/blood tests in the event
  of an injury
• LSMP