Title: POST EXPOSURE PROPHYLAXIS FOR HIV PEP 27 August 2003
1POST 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
2Who Needs Treatment After Exposure?
- Everyone!
- But not everyone needs medications
3Where Do I Get Information?
4PEPline
- 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
5http//www.ucsf.edu/hivcntr/Clinical_Resources/
Resources/PDFs/pep_steps.pdf
6Percutaneous Injuries
7Mucosal Exposures
8Cutaneous Exposures
9Standard Regimen
- Zidovudine (AZT, Retrovir) 200mg tid
- Lamivudine (3TC, Epivir) 150 mg bid
10Uses 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
11Advantages 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
12Advantages 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
13Disadvantages 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
14Alternative Regimen
- Stavudine (D4T, Zerit) 40mg bid
(if lt 60 kg use 30mg bid) - Lamivudine (3TC, Epivir) 150mg bid
15Potential Uses for Alternative Regimen
- exposed patient is unable to tolerate AZT
- desire to use a regimen less likely to cause side
effects
16Advantages 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
17Disadvantages 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
18Potential 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
19Advantages 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
21Disadvantages 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
22Choice of Protease Inhibitor
- Indinavir (IND, Crixivan) 800mg tid on an empty
stomach - Nefinavir (NFV, Viracept) 750mg tid with meals
23Indinavir (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
24Nefinavir (Viracept)
- diarrhea is common give Lomotil prescription
- otherwise well-tolerated
- best choice for use in combination with DDI
regimens
25Non-nucleoside Reverse Transcriptase Inhibitors
- Efavirenz (EFV Sustiva) 200mg 3 at hs
26Potential 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
27Advantages 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
28Disadvantages 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
29Common Questions
30What 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
31Specific 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
32Can 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.
33Is 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
34Why are both AZT 3TC being recommended after
HIV exposures?
- Due to AZT resistant virus being common
- Monotherapy is not used for HIV treatment
35What 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
36What 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
37When 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
38How long does treatment last after an exposure?
39Summary Of Recommendations
- Offer continued supportive care
- Offer compassion understanding
- Offer guidance
- Offer hope
40In Conclusion...
- Prevention is the best approach!
- Dont recap needles!
- Wash area with soap and water!
- Seek counseling and health care at once!
41MAHALO!