Post Exposure Prophylaxis for HIV Dr Abhimanyu Makane MBBS CHIV FHM(CMC,Vellore) AAHIVS Consultant HIV Physician Sterling Multispecialty Hospial,Nigdi,Pune Aditya Birla Memorial Hospital,Pune

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Outline Principal changes from previous PEP guidelines Health care personnel and exposure Risk of transmission of HIV Recommendations for the management of person potentially exposed to HIV HIV PEP Source patient testing Timing and duration of PEP Selection of PEP drugs Follow-up of exposed person Post-exposure testing Monitoring and management of PEP toxicity

Basis of Presentation WHO Adult ARV guidelines supplement- Dec 2014 DHHS Aug 2013 PEP guidelines

Principal Changes from Previous PEP Guidelines Elimination of risk stratification for exposure incidents 3-drug (or more) PEP regimen for all

Occupational Risk Exposures in HCP Percutaneous injury (needle-stick, cut) OR Contact of mucous membrane or non- intact skin WITH: Blood Tissue Other potentially infectious body fluids- (CSF, synovial, pleural, pericardial, peritoneal, or amniotic fluids; semen or vaginal secretions)

NOT Considered Infectious for HIV Feces Nasal Secretions Saliva Sputum Sweat Tears Urine Vomitus

Risk of Transmission of HIV

Assessment of the exposed person 4th generation ELISA for HIV HBV Vaccination status

Source Patient HIV Testing If possible, determine the HIV status of exposure source Unknown HIV status Window period HBV HCV

Timing and Duration of PEP Effect inversely proportional to time to initiation ASAP preferably within hours Point at which no benefit -not defined PEP should be taken for 4 weeks, if tolerated Appeared protective in occupational and animal studies

Post-exposure prophylaxis ARV regimens-for Adults TDF + 3TC (or FTC) The preferred backbone RAL, LPV/r, ATV/r or DRV/r Preferred third drug EFV Alternative options

ARV contraindicated as PEP Nevirapine

Special Considerations Pregnant Breastfeeding Paediatric

Follow-up of Exposed Patient If 4th-generation (p24 Ag/HIV Ab test) is used: HIV testing at baseline, 6 weeks, 12 weeks after exposure Barrier Protection for partner protection Close follow-up to diagnose toxicities early

Assess Prescription Followup Counsel & Support • Clinical assessment of exposure • Eligibility assessment for HIV PEP • HIV testing of exposed people and source if possible Counsel & Support • Risk of HIV • Risks and benefits of HIV PEP • Adherence counselling if PEP to be prescribed Prescription • PEP should be initiated ASAP post exposure • 28-day prescription Followup • HIV test at 3 months after exposure • Link to HIV treatment if possible • Provision of prevention intervention as appropriate