POST EXPOSURE PROPHYLAXIS FOR OCCUPATIONAL EXPOSURE TO HIV IN HEALTH CARE PERSONNEL

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POST EXPOSURE PROPHYLAXIS FOR OCCUPATIONAL
EXPOSURE TO HIV IN HEALTH CARE PERSONNEL

• Dr. Renu Dutta
• Professor
• Department of Microbiology
• Lady Hardinge Medical College
• New Delhi

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INTRODUCTION

• AIDS
• 40 Million (UNAIDS WHO)-2002
• Developing world gt95 of all HIV
• infection
• gt95 of all AIDS
  
• deaths
• Asia-7 million infected
• India-85,008-HIV infected patients
• 7, 012-AIDS cases

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EXPOSURE TO HIV INFECTION

• Occupational
• Non Occupational

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HIV SUSCEPTIBILITY

• S Heat - 56C X 30 mts /
• Boiling X few secs
• Most chemical germicides
• 0.5-1.0 Sod. Hypochlorite
• 70 Ethanol
• 2 Glutaraldehyde X 30 mts
• 3-4 Formaline
• Beta Propiolactone (1400 diln.)
• Povidone Iodine
• 
  

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BIOSAFETY

• Importance - No vaccine
• - Expensive treatment
• Practices - Universal Work
• Precautions
• - Effective use of
  sterilisation
• and disinfection
• - Safe disposal of hospital
  waste

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UNIVERSAL PRECAUTIONS

• Barriers Protection
• Hand washing
• Safe techniques
• Safe handling of
• Sharp items
• Specimens
• Spill of blood / body fluids
• Use of Disposable / Sterile items

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PEP FOR OCCUPATIONAL EXPOSURE TO HIV IN HCP

• Prevention of blood exposure
• Appropriate Post Exposure Management

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DATA ON PEP

• Retrospective Case Control Study of HCP
• ZDV efficacy in preventing perinatal transmission
• Evidence in animal studies

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DEFINITIONS

• HCP
• Any person whose activities involve contact with
  BLOOD/OTHER BODY FLUIDS from patients in a health
  care or lab setting or public safety setting

• EXPOSURE
• May place a HCP at risk for HIV infection and
  requires consideration of PEP

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TYPES OF EXPOSURE

• Percutaneous Injury
• Contact of mucous membrane or non-intact skin
• Contact with intact skin (Time Area)
• Bites resulting with blood exposure to either
  person involved

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TYPE AND AMOUNT OF FLUID / TISSUE

• Blood
• Fluids containing blood
• Potentially infectious fluid / tissue
• Semen
• Vaginal Secretions
• Human Breast milk
• CSF
• Synovial
• Pleural
• Peritoneal
• Pericardial
• Amniotic

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• Direct contact with concentrated virus
• (lab terminal illness)
• Not considered potentially infectious unless
• containing blood
• Faeces
• Nasal Secretions
• Saliva
• Sputum
• Tears
• Sweat
• Urine
• Vomitus

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RISK FOR OCCUPATIONAL TRANSMISSION OF HIV TO HCP

• Percutaneous exposure- 0.3
• Mucous membrane exposure- 0.09
• Non- intact skin exposure- case documented, not
  quantified
• Exposure to potentially infectious fluid other
  than blood- not quantified

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RETROSPECTIVE CASE CONTROL STUDY OF HCP

• Percutaneous exposure
• Blood large quantity
• Hollow bore needle
• Deep injury
• Blood exposure from source in terminal illness

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RETROSPECTIVE CASE CONTROL STUDY OF
HCP

• Source person viral load
• Plasma viral load
• Latently infected cell
• Low viral load (lt 1500 RNA copies/ mL)
• Host defenses HIV-CTL

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HIV SEROCONVERSION IN HCP

• Primary HIV Syndrome in 25 days (81)
• Seroconversion 46 days
• 95 seroconversion within 6 months

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RATIONALE FOR PEP CONSIDERATIONS

• Pathogenesis of HIV infection time course of
  early infection
• Use of antiretrovirals prevents infection
• Biological plausibility
• Evidences
• Risk and benefit of PEP to exposed HCP

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IMMEDIATE TREATMENT OF EXPOSURE SITE

• Wash wound skin site with soap and water
• Mucous membrane to be flushed with water
• Use of Antiseptic to be done ( no evidence)
• Expressing fluid by squeezing
• Application of caustic agents or injection of
  antiseptics into wound not recommended

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EXPOSURE CODE
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HIV STATUS CODE
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EVALUATION OF EXPOSURE EXPOSURE SOURCE

• Type of body substance involved
• Route and severity of exposure

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DETERMINATION OF PEP REGIMEN
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NO PEP RECOMMENDED FOR

• Potentially non infectious body material
• Intact skin exposure
• HIV negative status of source

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ANTIRETROVIRAL AGENTS FOR PEP

• NRTI ZDV, 3TC, d4T, ABC
• NNRTI Nevirapine, Efavirenz,
• Delaviridine
• P.I. Indinavir, Nelfinavir, Saquinavir,
• Ritonavir

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BASIC 2-DRUG REGIMEN

• Zidovudine(ZDV, 300mg BD)
• Lamivudine(3TC, 150mg BD)
• Lamivudine(3TC, 150mg BD)
• Stavudine(d4T, 40mg BD
• 30mg for wt.lt60kg)
• Didanosine(ddI, 200mg BD
• 125 mg BD for wt. lt 60kg)
• Stavudine(d4T, 40mg BD)

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EXPANDED 3 DRUG REGIMEN

• Basic regimen plus one of the following
• Indinavir (IDV) 800mg TDS
• Nelfinavir (NFV) 750 mg TDS
• Efavirenz (EFV) 600mg OD- to PI in
• 
  source virus
• Abacavir (ABC) 300mg BD-careful monitoring of
  hypersensitivity

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TIME DURATION OF PEP

• Immediate
• Within 24 36 hrs
• After 36 hrs initiate reassess
• After 1 wk, initiate PEP if increased risk of
  transmission
• Optimal duration 4 wks

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TOXICITY OF PEP

• Common
• Nausea
• Malaise
• Headache
• Anorexia

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MONITORING MANAGEMENT OF PEP TOXICITY

• Baseline and 2 wks after starting PEP
• Complete blood count
• Renal function test
• Hepatic function test
• Evidence of hyperglycemia, hematuria, hemolytic
  anemia, hepatitis, crystalluria

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COST OF PEP

• BASIC REGIMEN
• A) ZDV(300mg) 3TC (150mg)
• Cipla- Duovir- Rs. 274/ 10 tabs
• Zydus Bigeri-Lamuzid- Rs. 470/ 10 tabs
• Immunus Aurobindo-Zidovex L- Rs. 280 / 10 tabs
• B) d4T(40 mg) 3TC(150mg)Immunus Aurobindo
• 
  - Rs. 1020/ mth
• FOR EXPANDED REGIMEN
• Indinavir(400mg)-Immunus Aurobindo-Indivex- Rs.
  1200 / 10 tabs
• Nelfinvair(250mg)-Immunus Aurobindo- Nelvex- Rs.
  3600 / 90 tabs
• Efavirenz(200mg)-Immuno Aurobindo-Viranz- Rs.
  3600 / 90 tabs

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PEP MANAGEMENT FOLLOW UP OF HCP

• Prompt reporting
• Evaluation
• Counselling
• Post exposure testing of HCP
• Medical evaluation
• Availability of antiretroviral drugs and timely
  administration
• HIV-Ab testing by EIA upto 6 mths(6 wks, 12 wks,
  6 mths)
• Look for illness in HCP

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THANK YOU