POST EXPOSURE PROPHYLAXIS FOR HIV PEP 27 August 2003 - PowerPoint PPT Presentation

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POST EXPOSURE PROPHYLAXIS FOR HIV PEP 27 August 2003

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POST EXPOSURE PROPHYLAXIS FOR HIV (PEP) 27 August 2003 ... exposure is especially risky (very large volume, high titer) ... an exposure to blood from a ... – PowerPoint PPT presentation

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Title: POST EXPOSURE PROPHYLAXIS FOR HIV PEP 27 August 2003


1
POST EXPOSURE PROPHYLAXIS FOR HIV (PEP)27 August
2003
  • The Very Rev. Drew A. Kovach, M.D., M.Div.
  • Director of HIV Services
  • Kaiser Permanente Hawaii
  • 808.432.2383
  • dkovach_at_hawaii.rr.com

2
Who Needs Treatment After Exposure?
  • Everyone!
  • But not everyone needs medications

3
Where Do I Get Information?
4
PEPline
  • The National Clinicians' Post-Exposure
    Prophylaxis Hotline
  • 1-888-448-4911
  • 24 hours a day 7 days a week
  • PEP Guidelines http//www.ucsf.edu/hivcntr/Clinic
    al_Resources/PEPGuidelines.html

5
http//www.ucsf.edu/hivcntr/Clinical_Resources/
Resources/PDFs/pep_steps.pdf
6
Percutaneous Injuries
7
Mucosal Exposures
8
Cutaneous Exposures
9
Standard Regimen
  • Zidovudine (AZT, Retrovir) 200mg tid


  • Lamivudine (3TC, Epivir) 150 mg bid

10
Uses for Standard Regimen
  • default regimen for initial triage
  • good regimen when source patient has not been
    treated
  • good regimen when HIV tests are pending
  • probably a safe regimen for pregnant health care
    workers

11
Advantages of Standard Regimen
  • recommended by US Public Health Service (USPHS)
    for PEP
  • AZT is associated with decreased odds of
    infection in the CDC case-control study of
    occupational HIV infection
  • AZT has been used more than other drugs for PEP
    in health care workers
  • side effects are predictable
  • side effects are manageable
  • serious toxicity is rare when used for PEP in
    health care workers

12
Advantages of Standard Regimen
  • AZT 3TC may be active against some strains of
    AZT-resistant HIV
  • can be given as a bid regimen can be given as a
    combination tablet (AZT 3TC Combivir) one
    tablet twice a day with food

13
Disadvantages of Standard Regimen
  • side effects are common low adherence
  • AZT is "unpopular" in some communities
  • source patient may have resistant/cross-resistant
    HIV
  • management and follow-up of patients with
    pre-existing anemia is more complicated
  • delayed toxicity (oncogenic/teratogenic
    potential) unknown

14
Alternative Regimen
  • Stavudine (D4T, Zerit) 40mg bid
    (if lt 60 kg use 30mg bid)
  • Lamivudine (3TC, Epivir) 150mg bid

15
Potential Uses for Alternative Regimen
  • exposed patient is unable to tolerate AZT
  • desire to use a regimen less likely to cause side
    effects

16
Advantages of Alternative Regimen
  • very well-tolerated in patients with HIV
    infection good adherence
  • serious toxicity appears to be rare in patients
    with HIV infection
  • bid regimen
  • may be effective against HIV strains from source
    patients who are taking AZT
  • very active regimen in patients with HIV
    infection

17
Disadvantages of Alternative Regimen
  • not currently explicitly recommended for PEP by
    USPHS
  • no data demonstrate effectiveness for PEP
  • source patient may have resistant/cross-resistant
    HIV
  • delayed toxicity (oncogenic/teratogenic
    potential) unknown
  • minimal data about experience when used for PEP
    in health care workers

18
Potential Uses of Protease Inhibitors
  • source patient is taking one of the drugs in the
    standard or preferred alternate dual combination
    regimen (especially when resistance is suspected)
  • exposure is especially risky (very large volume,
    high titer)
  • exposed patient and/or treating clinician
    strongly prefer this option

19
Advantages of Protease Inhibitors (all
theoretical)
  • drug with a second mechanism of action may
    enhance efficacy of PEP
  • triple drug regimens are more active in
    HIV-infected patients than are dual drug regimens
    and the same could be true for PEP
  • in case PEP fails, it may be better to have
    health care worker on a three-drug regimen during
    seroconversion

20
Disadvantages of Protease Inhibitors
  • no data demonstrate that protease inhibitors are
    active for PEP
  • no data demonstrate that adding a protease
    inhibitor will increase PEP efficacy
  • source patient may have resistant HIV
  • class resistance - if source patient is resistant
    to one, may be resistant to all
  • drug-drug interactions complicate treatment
  • serious toxicities (diabetes, nephrolithiasis)
    can occur

21
Disadvantages of Protease Inhibitors
  • side effects common anticipate low adherence
  • add to complexity of treatment regimen
    anticipate low adherence
  • relatively new spectrum of toxicities may be
    incomplete
  • delayed toxicity (oncogenic/teratogenic
    potential) unknown
  • minimal data about experience when used for PEP
    in health care workers

22
Choice of Protease Inhibitor
  • Indinavir (IND, Crixivan) 800mg tid on an empty
    stomach
  • Nefinavir (NFV, Viracept) 750mg tid with meals

23
Indinavir (Crixivan)
  • potent HIV inhibitor
  • should drink 8 glasses of fluid /day to prevent
    nephrolithiasis
  • hyperbilirubinemia and ? LFTs not rare (avoid
    IND during late pregnancy)
  • otherwise well-tolerated

24
Nefinavir (Viracept)
  • diarrhea is common give Lomotil prescription
  • otherwise well-tolerated
  • best choice for use in combination with DDI
    regimens

25
Non-nucleoside Reverse Transcriptase Inhibitors
  • Efavirenz (EFV Sustiva) 200mg 3 at hs

26
Potential Uses of NNRTIs
  • Consider in cases where the source patient is on
    other antiviral drugs and no other options are
    sensible (especially when resistance is
    suspected)
  • Consider when the exposed person cannot tolerate
    the drugs used in the above regimens

27
Advantages of NNRTIs
  • do not require phosphorylation before activation,
    and may be active earlier than other reverse
    transcriptase inhibitors (this is likely to be
    only a theoretical advantage of no clinical
    benefit?)
  • are commonly used now as often as PIs

28
Disadvantages of NNRTIs
  • these drugs are associated with rash (early
    onset) that can be severe
  • differentiating between early NNRTI rash and
    acute infection can be difficult and cause
    extraordinary concern for the exposed person
  • minimal data about experience when used for PEP
    in health care workers
  • delayed toxicity (oncogenic/teratogenic
    potential) unknown
  • CNS side effects of Efavirenz

29
Common Questions
30
What is the risk for getting HIV after a
needlestick, an injury with a sharp instrument,
or a splash?
  • About 1 in 300, or 0.3
  • Less than 0.1 if post-exposure medication taken
  • The risk for infection from a bloody splash to
    mucous membranes or to open skin is very low -
    less than 1 in 1000

31
Specific Factors Increase the Risk
  • an exposure to blood from a terminally-ill AIDS
    patient
  • an exposure caused by a needle which was used in
    a blood vessel
  • an exposure caused by a visibly-bloody device
  • a deep puncture

32
Can treatment after exposure prevent HIV
infection?
  • workers who took only AZT after needlestick
    exposures to HIV was 79 lower than those who
    were not treated.
  • The CDC issued new treatment recommendations for
    HIV exposures in 2001 (MMWR, June 29, 2001). AZT
    3TC after serious exposures to HIV.

33
Is it true that some people have taken AZT after
an exposure and still become infected?
  • Yes 19 published cases in the world
  • We dont however, know how many were exposed took
    medication and did not get infected

34
Why are both AZT 3TC being recommended after
HIV exposures?
  • Due to AZT resistant virus being common
  • Monotherapy is not used for HIV treatment

35
What about adding other drugs?
  • In special serious exposure cases or when
    resistant HIV is suspected
  • Protease inhibitors and NNRTIs can be considered
    with expert consultation

36
What are the side effects of treatment?
  • 66 had some side effects with AZT 3TC
  • Headache
  • Nausea and vomiting
  • Fatigue
  • 70 had side effects with PIs
  • Liver toxicity
  • Kidney stones
  • Diarrhea and abdominal distress

37
When should treatment be started?
  • As soon as possible
  • Within 1-2 hours
  • When in doubt start
  • Treatment can be stopped when risk/benefits have
    been determined

38
How long does treatment last after an exposure?
  • 28 days

39
Summary Of Recommendations
  • Offer continued supportive care
  • Offer compassion understanding
  • Offer guidance
  • Offer hope

40
In Conclusion...
  • Prevention is the best approach!
  • Dont recap needles!
  • Wash area with soap and water!
  • Seek counseling and health care at once!

41
MAHALO!
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