Post-Exposure Prophylaxis of HIV (PEP)

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Post-exposure prophylaxis is the use of cART to prevent HIV transmission. Non-occupational exposure to HIV in children is mostly due to sexual abuse. In adults, exposure to HIV is mostly associated with occupational injuries. The risk of acquiring HIV infection after occupational exposure to HIV-infected blood is low (1:300 after percutaneous exposure to <1:1000 after mucocutaneous exposure).

There is no risk of transmission when the skin is intact. Factors associated with an increased risk include deep injury, visible blood on the device that caused the injury, injury with a large-bore needle from artery or vein, and unsuppressed HIV viral load in source patient. Body fluids and materials that pose a risk of HIV transmission are 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 visibly blood-stained fluid, and fluid from burns or skin lesions. Other blood-borne infections are hepatitis B and hepatitis C viruses. Thus all HCWs should receive HBV vaccination.

Management of occupational exposure to infectious substances includes the following steps:

Immediately after exposure:

  • Clean the site: wash skin wounds with soap and running water. DO NOT squeeze, allow the wound to freely bleed. If the exposed area is an eye or mucous membrane, flush with copious amounts of clean water. DO NOT USE BLEACH or other caustic agents/disinfectants to clean the skin.
  • Contact your In-Charge or Supervisor.
  • Consult the clinical officer or medical officer, who does the following:
    Determine the need for post-exposure prophylaxis (PEP) based on the risk of transmission and risks and benefits of taking (or not taking) cART.

PEP Recommendations based on the risk category

Risk category cART  Duration
No risk: intact skin Not recommended  

Medium risk:

  • invasive injury
  • no blood visible on needle

Preferred

  • TDF or TAF + XTC + DTG

Alternatives:

  • TDF or TAF + XTC + DRV-r
  • TDF or TAF + XTC + LPV-r
  • TDF or TAF + XTC + ATV-r
  • AZT + 3TC + LPV-r (children < 20kg)
  • AZT + 3TC + DTG (children ≥ 20kg)
  • TAF + FTC + DTG (children ≥ 25kg)
 28 days

High risk:

  • large volume of blood/fluid
  • known HIV-infected patient
  • large-bore needle
  • deep extensive injury
Penetrative sexual abuse

*For patients with CrCl <50mL/min, replace TDF with AZT

**DTG is effective against both HIV 1 and 2 and prevents integration of the viral DNA into the host DNA. It should be avoided in pregnancy and for HIV/TB patients on Rifampicin, the dose of DTG should be 50mg twice daily instead of the regular 50mg once daily. For intolerance to DTG (such, insomnia, anxiety, depression), use a recommended PI

***For patients who are intolerant to ATV-r or if the source is HIV-2 infected and cannot tolerate DTG, LPV-r should be used.

 

Clients on PEP should have an HIV test before starting PEP, and a repeated test at 6 weeks and 3 months, consecutively. While on PEP, the client should be reviewed and offered appropriate laboratory investigations.