Occupational HIV Exposure Prophylaxis Dr Truong Anh Tan June 30 th, 2010

Infected post-exposure rate/1000 Blood infusion 900 Blood infusion 900 IDU (shared needle)6,7 IDU (shared needle)6,7 Anal sex receiver5,0 Anal sex receiver5,0 Needlestick3,0 Needlestick3,0 Vaginal sex female1,0 Vaginal sex female1,0 Anal sex giver0,65 Anal sex giver0,65 Vaginal sex male0,5 Vaginal sex male0,5 Oral sex receiver0,1 Oral sex receiver0,1 Oral sex giver0,05 Oral sex giver0,05

3. Estimated Pathogen-Specific Seroconversion Rate Per Exposure for Occupational Needlestick Injury AETC

4 Type of Exposure Way Involved in Transmission of HIV to Health Care Workers

5 Source of HIV Involved in HIV Transmission to Health Care Worker AETC

6 Risk Factor Odds Ratio Confidence Interval Deep Injury Visibly Bloody Device Device Used in Artery or Vein Terminally Ill Source Patient Use of Zidovudine for PEP P<0.01 for all associations Risk Factors for HIV Transmission with Occupational Exposure to HIV- Infected Blood

7 Other Possible Risk Factors Hollow bore vs solid bore Hollow bore vs solid bore No documented cases to date of seroconversion from suture needles No documented cases to date of seroconversion from suture needles Glove use Glove use 50% decrease in volume of blood transmitted 50% decrease in volume of blood transmitted Mucous membrane exposure Mucous membrane exposure Mosquitoes bite? Mosquitoes bite?

8 Standard Precautions Definition Definition Standards developed to prevent exposure and transmission of disease in occupational setting Standards developed to prevent exposure and transmission of disease in occupational setting Provide guidance for the safe handling of infectious material Provide guidance for the safe handling of infectious material

9 Components of Standard Precautions Hand washing Hand washing Use protective barriers when indicated Use protective barriers when indicated Gloves: mucus membranes, body fluids, broken skin Gloves: mucus membranes, body fluids, broken skin Goggles: procedures Goggles: procedures Masks: procedures Masks: procedures

10 Components of Standard Precautions (2) Sharps and waste - handle with gloves and dispose in designated containers Sharps and waste - handle with gloves and dispose in designated containers Needles Needles Scalpels Scalpels Suture material Suture material Bandages Bandages Dressings Dressings Anything contaminated with any body fluid Anything contaminated with any body fluid

11 Handling with Disposing Sharps Handling with Disposing Sharps Do not recap needles! Do not recap needles! Put containers within arms reach Put containers within arms reach Use adequate light source when treating patients Use adequate light source when treating patients Wear heavy-duty gloves when transporting sharps Wear heavy-duty gloves when transporting sharps Incinerate used needles to a sufficient temperature to melt Incinerate used needles to a sufficient temperature to melt Keep sharps out of reach of children Keep sharps out of reach of children

12 Components of Standard Precautions (3) Re-usable instruments  must be thoroughly disinfected Re-usable instruments  must be thoroughly disinfected Speculums Speculums Surgical tools Surgical tools Thermometers Thermometers Immunizations for Healthcare Workers Immunizations for Healthcare Workers Hepatitis A and B Hepatitis A and B

13 Recommended Antiseptic Solutions Alcohol 70% Alcohol 70% Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub) Chlorhexidine, 2-4% (e.g. Hibtane, Hibiscrub) Iodine 3% Iodine 3% Iodophores % (e.g. Betadine) Iodophores % (e.g. Betadine)

14 Recommended Disinfectants Chlorine, 0.5% (Barkina) Chlorine, 0.5% (Barkina) Sedex and Ghion brands contain 5% Chlorine, dilute for use Sedex and Ghion brands contain 5% Chlorine, dilute for use Glutaraldehyde, 2-4% (e.g. Cidex) Glutaraldehyde, 2-4% (e.g. Cidex) Formaldehyde, 8% Formaldehyde, 8% Hydrogen peroxide, 6% Hydrogen peroxide, 6% Soak the instrument for 20 minutes after decontamination and cleaning Soak the instrument for 20 minutes after decontamination and cleaning

HIV AB: for both (giver and receiver) HIV AB: for both (giver and receiver) Hepatitis : B & C Hepatitis : B & C CBC CBC SGOT/SGPT SGOT/SGPT Blood Glucose Blood Glucose  1  3  6 th month  1  3  6 th month Management of Occupational Exposure

16 Diagnostic Testing Diagnostic Testing 1 mil 100,000 10,000 1, _ HIV RNA HIV-1 Antibodies Exposure Symptoms Days HIV RNA Ab 7 Image courtesy of The Center for AIDS Information & Advocacy,

17 Cell free HIV Skin or mucosa 24 hours48 hours 1.HIV co-receptors, CD4 + chemokine receptor CC5 Immature Dendritic cell 3.Mature Dendritic cell in regional LN undergoes a single replication, which transfers HIV to T- cell Via lymphatics or circulation T-cell PEP Burst of HIV replication 2.Selective of macrophage- tropic HIV The Early Stages of HIV Infection

19 Wound Care Gently wash wounds with soap and water/ 5 minutes  alchol 70% 5 minutes (don’t scrub vigorously) Gently wash wounds with soap and water/ 5 minutes  alchol 70% 5 minutes (don’t scrub vigorously) Allow wounds to bleed freely Allow wounds to bleed freely Irrigate exposed mucosal surfaces with sterile saline Irrigate exposed mucosal surfaces with sterile saline

20 Post Exposure Prophylaxis (PEP) Definition: Definition: Use of therapeutic agent to prevent establishment of infection following exposure either occupationally or non-occupationally to pathogen Use of therapeutic agent to prevent establishment of infection following exposure either occupationally or non-occupationally to pathogen Roles in Occupational Exposure: Roles in Occupational Exposure: HIV prevention HIV prevention HBV prevention HBV prevention  Tests before ARVs therapy

21 Step 1: Does This Patient Need HIV PEP? Source patient HIV +HIV - Unknown / Unwilling to get tested* PEP High back- ground risk Low back- ground risk No PEP *CDC recom: usually PEP unnecessary; consider use if source patient is high risk

HIV NegativeHIV Positive Asymptomatic/high CD4 = HIV SC 1 Advanced disease, primary infection or low CD4 =HIV SC 2 HIV Status Unknown or Source Unknown = HIV SC Unknown No PEP Step 2: Determine HIV Status Code of Source (HIV SC) PEP No PEP or + PEP with 2 drugs

CDC Sep 2005

25 Occupational HIV PEP 2 drug regimen 2 drug regimen Zidovudine plus lamivudine (combivir) Zidovudine plus lamivudine (combivir) Stavudine plus Lamivudine Stavudine plus Lamivudine Tenofovir plus lamivudine Tenofovir plus lamivudine 3 drug regimen 3 drug regimen LPV/r or Indinivr or Nelfinavir plus NRTI backbone LPV/r or Indinivr or Nelfinavir plus NRTI backbone Efavirez plus NRTI backbone Efavirez plus NRTI backbone Consider resistance potential of source patient Consider resistance potential of source patient Don’t use NVP (hepatotoxic) Don’t use NVP (hepatotoxic)  When to start  ASAP  PEP no efficacy after 72 hours

PEP Guideline from MOH - PEP 1: AZT + 3TC AZT: 300mg bid & 3TC: 150 mg bid. AZT: 300mg bid & 3TC: 150 mg bid. - PEP 2: 3TC + d4T 3TC: 150mg bid & d4T: 30-40mg bid. < 60 kg, d4T: 30 mg bid. > 60 kg, d4T: 40 mg bid. AZT(Zidovudine);3TC(Lamivudine);D4T(Stavudine)

Advanced PEP (for high risk) PEP 1 or 2 plus 1of following agents: - NFV: 1,25 g bid. - EFV: 300 mg bid - LPV/r: 500 mg bid (recommended)  28 days duration (MOH guideline for PEP updated on 9/2009)

28 Follow-up HIV Testing -CDC: HIV Ab at 6 th week, 3 rd month, 6 th month -Extended HIV Ab testing at 12 months recommended if a source patient co-infected HCV - VL testing not recommended unless Primary HIV Infection (PHI) suspected - -Early diagnosis: HIV RNA PCR at 3 th week MMWR June 29, 2001 / 50(RR11);1-42.

Thank you for your attention! your attention!