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Non-Occupational Post Exposure Prophylaxis NPEP. Jude Armishaw Victorian NPEP Service The Alfred. What is PEP?. Post-exposure prophylaxis (PEP) A treatment following an exposure to an infection Aim is to prevent the infection from becoming established in the host HIV PEP

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Non occupational post exposure prophylaxis npep
Non-Occupational Post Exposure ProphylaxisNPEP

Jude Armishaw

Victorian NPEP Service

The Alfred


What is pep
What is PEP?

  • Post-exposure prophylaxis (PEP)

    • A treatment following an exposure to an infection

    • Aim is to prevent the infection from becoming established in the host

  • HIV PEP

    • Use of antiretroviral medications to reduce the risk of transmission of HIV

    • Same drugs as used to treat HIV infection

    • Started with 72 hours of exposure

    • Taken for one month (28 days)


NPEP

  • Non occupationalpost-exposure prophylaxis

    • Use of PEP outside the healthcare setting

    • Sexual exposure

    • Injecting drug use exposure


Hiv transmission risk
HIV Transmission Risk

=

RISK CARRIED BY THE EXPOSURE

X

RISK THAT THE SOURCE IS HIV POSITIVE



Hiv transmission risk1
HIV Transmission Risk

  • Risk estimates only

  • HIV transmission heterogeneous

  • Per-contact risk for any individual may be considerably higher than the average

  • More useful for assessing population based risk rather than absolute risk for an individual


Cofactors increasing hiv transmission
Cofactors increasing HIV transmission

  • High plasma viral load in the source partner

  • Presence of STI, especially genital ulcer disease and symptomatic gonorrhoea in source or exposed person

    Source ~ increases viral load

    Exposed ~ increases dendritic cells

  • A breach in mucosal integrity of exposed person (e.g. scratch, cut) through which host dendritic cells capture HIV



What is the risk where the partner s hiv status is unknown
What is the risk where the partner’s HIV status is unknown?

  • Most common presentation for NPEP is MSM following unprotected anal sex with an anonymous partner

  • How do we assess risk where source HIV status unknown?

  • Seroprevalence


Hiv transmission risk2
HIV Transmission Risk unknown?

=

RISK CARRIED BY THE EXPOSURE

X

RISK THAT THE SOURCE IS HIV POSITIVE




Efficacy and evidence
Efficacy and evidence unknown?

Animal data

  • Start within 72 hours of exposure

  • Sooner the better

  • Taken for 28 days

  • Completion of course with good compliance

    HCW case control study and MTC

  • Reduces HIV transmission by up to 80%


Recommended npep regimens
Recommended NPEP Regimens unknown?

2- drug regimen

Truvada

(Tenofovir 300mg/Emtricitabine 200mg)

One tablet daily for 28 days

Or

Combivir

(Zidovudine 300mg/Lamivudine 150mg)

One tablet twice daily for 28 days

3- drug regimen

One of the above 2 drug combinations

Plus

Kaletra

(Lopinavir 200mg/Ritonavir 50mg)

Two tablets twice daily for 28 days


Addition of 3 rd drug
Addition of 3 unknown?rd drug

  • Higher risks (RAI, IAI, RVI, IVI, IDU w pos source)

    • But … no data to show 3 drug NPEP regimen more efficacious than 2 drug regimen

    • Based on evidence that 3 drugs is more effective in treating established HIV (HAART)

  • Source ARV Hx

    • Where resistance genotype indicates drug resistance tailor NPEP regimen


Side effects
Side effects unknown?

  • Side effects in 45-75% NPEP patients

    • Nausea

    • Headache

    • Fatigue & lethargy

    • Diarrhoea

  • Adherence to full 28 day course important

  • Completing a 2 drug regimen may exceed the benefit of a poorly tolerated 3 drug regimen


Npep service
NPEP Service unknown?

Service commenced Aug 2005

Alfred Hospital, VAC and DHS

Hub and Spoke Model

Hub is Alfred Hospital

0.8 FTE Clinical Nurse Consultant (CNC)

0.3 I.D. Physician

0.3 Clinical Psychologist

5 Registered Nurses on-call 24/7 for 1800 number


Npep spoke clinics in metropolitan rural vic
NPEP spoke clinics in Metropolitan & Rural Vic unknown?

Metropolitan

Prahran Market Clinic

Centre Clinic

Carlton Clinic

MSHC

Northside Clinic

Recreation Medical Centre

Alfred ED (A/H only)

The Alfred ID Clinic

Middle Park Clinic

Richmond Hill Medical Centre

Monash Medical Centre

Royal Melbourne

Rural

Bendigo

Shepparton

Geelong

Wodonga

Warrnambool


Telephone information line 1800 889 887 24 hours fri mon and 0830 to midnight tue thurs
Telephone Information Line unknown?1800 889 887(24 hours Fri – Mon and 0830 to midnight Tue – Thurs)

Staffed by RNs on rotating roster

RNs trained in

HIV

Sexual Health

NPEP

Telephone Counselling Skills


Community exposure to HIV unknown?

Call 1800 889 887

Nurse assess and refer to spoke clinic if need NPEP

Patient go to spoke clinic

Given starter pack (7 days)

Paperwork faxed to NPEP Service and remainder packs sent to clinic for patient to collect

Patient return at week 1 for remaining 21 days medication

Patient return for week 4 and 12 follow-up


Case 1
Case 1 unknown?

A young man tells you that he was in a sauna last night and had insertive

anal sex with an anonymous partner. He did not use a condom.

What is his risk of getting HIV from this exposure?

What factors need to be assessed?

Is NPEP recommended?


Case 2
Case 2 unknown?

A heterosexual man tells you that he went to see a female sex worker

in Melbourne yesterday and had insertive penile-vaginal sex. He used

a condom, but when he withdrew he noticed that the condom had

broken.

What is his risk of getting HIV from this exposure?

Would you recommend that he take NPEP?

Would the risk be any different if it had happened in Thailand?


Case 3
Case 3 unknown?

A woman tells you she was walking along St Kilda beach and felt a sharp

sting in her foot. When she looked down she saw that she had stepped on

a needle.

What is the risk of getting HIV from this exposure?

Is NPEP recommended?

What are the other factors that need to be assessed?


Case 4
Case 4 unknown?

A man tells you that he had unprotected receptive anal sex 2 days ago

with a casual partner that he met on the internet. Last night this partner

told him that he has HIV.

What is his risk of getting HIV from this exposure?

Is NPEP recommended?

What other factors would you need to assess?


Case 5
Case 5 unknown?

A young man is very distressed that he had unprotected receptive oral sex

last night with an anonymous partner that he met at a bar. The partner

ejaculated into his mouth.

What is the risk of HIV from this exposure?

Is NPEP recommended?

What other factors would you need to assess?


Feedback
Feedback unknown?



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