1. 4th Year Student Electives overseas HIV and Post- Exposure Prophylaxis Dr Eric Monteiro Clinical Director Department of Genitourinary Medicine

2. 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

3. 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

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

5. 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

6. 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, <1 in 1000. No risk of transmission where intact skin is exposed to HIV infected blood

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. Risk Assessment (2) Circumstances of exposure –Assess if exposure was significant Types of exposure with contaminated instruments/body fluids associated with significant risk 1.Percutaneous injury (needles, instruments, bites which break skin) 2.Exposure of broken skin (abrasions, cuts) 3.Exposure of mucous membranes inc. the eye, mouth

14. 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)

15. 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/04/08/36/40/040 83640.pdfhttp://www.dh.gov.uk/assetRoot/04/08/36/40/040 83640.pdf

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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?

22. 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 don’t get a response!) Consider insurance to cover repatriation in event of significant injury requiring PEP.

23. 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