POST EXPOSURE PROPHYLAXIS (PEP) FOR HIV IN MALAYSIA

What is PEP?

PEP (post-exposure prophylaxis) means taking medicine to prevent HIV after a possible exposure. PEP Must Be Started Within 72 Hours of Possible Exposure to HIV.PEP Must Be Started Within 72 Hours of Possible Exposure to HIV

Talk right away (within 72 hours) to your health care provider, an emergency room doctor, or an urgent care provider about PEP if you think you’ve recently been exposed to HIV:

1)during sex (for example, if the condom broke), 2)through sharing needles, syringes, or other equipment to inject drugs (for example, cookers), or if you’ve been sexually assaulted. 3)Through body fluids

The sooner you start PEP, the better. Every hour counts. If you’re prescribed PEP, you’ll need to take it daily for 28 days.

PEP is for Emergency Situations

PEP is given after a possible exposure to HIV. PEP is not a substitute for regular use of other HIV prevention. PEP is not the right choice for people who may be exposed to HIV frequently.I f you are at ongoing risk for HIV, such as through repeated exposures to HIV, talk to your health care provider about PrEP (pre-exposure prophylaxis) How well does PEP work? If taken within 72 hours after possible exposure, PEP is highly effective in preventing HIV. But to be safe, you should take other actions to protect your partners while you are taking PEP. This includes always using condoms with sexual partners and not sharing needles, syringes, or other equipment to inject drugs.

Is there any side effects? PEP is safe but may cause side effects like nausea in some people. In almost all cases, these side effects can be treated and aren’t life-threatening. PEP and Workplace If you think you’ve been exposed to HIV at work, see a health care provider, an emergency room doctor, or an urgent care provider right away. Report your exposure to the appropriate person at work and seek medical attention immediately. PEP must be started within 72 hours after an exposure. The sooner you start PEP, the better. Every hour counts. Careful practice of standard precautions can help reduce the risk of exposure while caring for patients with HIV. Learn more about occupational exposure to HIV and how to prevent it PEP and Medication Updated guidelines from the United States Public Health Service (USPHS) and New York State Department of Health AIDS Institute recommend that, after any occupational exposure to HIV, healthcare personnel should immediately receive a postexposure prophylaxis (PEP) three-drug regimen. Specific recommendations also include the following:

1)Primary prevention strategies are emphasized, along with prompt reporting and management of occupational exposures.

2)The HIV status of the source of the exposure should be determined to guide the need for HIV PEP; if the HIV status of the source is unknown, it should be determined, usually with a rapid and reliable test such as the fourth-generation HIV test. If there is a concern about a false-negative result (eg, result is negative but there has been a risk for HIV transmission to the source prior to test detection, about 4-10 days for tests that detect Ag and/or Ab, including the fourth-generation test), plasma HIV RNA (HIV viral load) testing of the source is recommended.

3)PEP should be initiated as soon as possible, ideally within hours of exposure; a first dose of PEP should be offered to the exposed worker while the evaluation is underway if HIV transmission is considered credible.

4)A PEP supply for 3-5 days is available for urgent use, and the exposed worker obtains a continuous supply to complete the 28-day course.

5)Follow-up appointments should begin within 72 hours of HIV exposure and should include follow-up HIV testing, monitoring for drug toxicity, and counseling.

6)Repeat HIV testing should be obtained at 6 weeks and 4 months postexposure. Testing should be performed using the fourth-generation assay; if a fourth-generation assay is unavailable, repeat HIV testing should be obtained at 6 weeks, 12 weeks, and 6 months postexposure. An HIV viral load should be obtained if the exposed healthcare worker has symptoms of acute retroviral syndrome.

How Does PEP Work?

The same drugs that treat HIV can fight the virus as it tries to infect you. These medications are called antiretrovirals. PEP is a combination of three drugs. You take them once or twice a day for 28 days: For adults, the CDC recommends tenofovir, emtricitabine (these two drugs come in one pill), and a third drug, either raltegravir or dolutegravir. Women who are in early pregnancy, who are sexually active and could become pregnant while taking PEP, or who were sexually assaulted without birth control should take raltegravir rather than dolutegravir because of a risk of birth defects. Children 2 or older who need PEP usually get the same drugs in different doses.

Side effects of PEP include: Upset stomach, fatigue, headache, diarrhea, insomnia and rarely, the drugs can cause serious health issues, including liver problems. PEP and Risk Factors The risk of HIV transmission after exposure to body fluids from an HIV-infected patient is generally low. Risks associated with the 3 main routes of exposure are as follows:

1)Percutaneous exposure - Risk with an HIV-positive source, approximately 0.3%; risk is increased by hollow-bore needles, visibly bloody devices, deep injuries, and source person with terminal illness reflecting higher titer of HIV

2)Cutaneous exposure (ie, via nonintact skin) - Risk with an HIV-positive source, less than 0.09%

3)Mucous membrane exposure - Risk with an HIV-positive source, approximately 0.09%; risk is increased with a high viral load in the source and large-volume exposure PEP and Management

Initial management steps for healthcare personnel exposed to HIV include the following:

1)Immediate decontamination (if not already performed by the healthcare worker) - For percutaneous or cutaneous exposure, washing of the area with soap and water; for mucous membrane exposure, copious irrigation of the area with water or sterile saline; for puncture wounds, cleanse with alcohol-based hand wipes; for eye exposures, irrigation with copious amounts of sterile water or saline

2)Initiation of institutional PEP plan - Reporting of exposure; confirmation of medication availability; provision of the initial supply; authorizing release of the drugs; determination of how the healthcare worker will obtain the medications to complete the 28-day regimen.

3)Ordering of blood tests, immediate treatment, and follow-up within 72 hours, at which time further review and evaluation can be carried out

4)Source of exposure - Voluntary testing for HIV, hepatitis C virus antibody, and hepatitis B surface antigen (HBsAg); if HIV test is positive, confirmatory HIV 1/2 Ab differentiation immunoassay; if HIV infection is known to be present, obtain relevant information about disease stage

5)Healthcare worker - Testing for HIV, HCV antibody, HBsAg, and hepatitis B surface antibody (HBsAb); in females of child-bearing age, pregnancy testing; if HIV PEP is initiated, baseline complete blood (CBC) count, renal and hepatic function

When indicated, PEP should be initiated as soon as possible (ideally ≤2 hours and generally ≤72 hours) after exposure. The approach to PEP depends on the type of exposure, the source, and the HIV status of the source.

Follow-up measures should include the following:

1)Refraining from donation of blood, tissue, semen, or organs

2)Avoiding sexual intercourse without using barrier precautions; avoiding breastfeeding if possible; informing the provider if the at-risk healthcare worker is pregnant

3)Follow-up HIV antibody testing at 6 weeks and 4 months if using fourth-generation HIV test; if fourth-generation HIV test is unavailable, testing should be conducted at 6 weeks, 12 weeks, and 6 months

4)Rechecking of CBC, renal function, and hepatic function at 2 weeks PEP and Contraindications

According to the World Health Organization (WHO), PEP is contraindicated if the exposed person is already HIV-positive due to a previous exposure, if the patient is chronically exposed to HIV, if the exposure does not pose a risk of transmission, or if the exposure occurred more than 72 hours previously.

Because nonoccupational postexposure prophylaxis (nPEP) carries a risk for adverse effects and toxicities, it should be used for only infrequent exposures. Persons who engage in behaviors that result in frequent recurrent exposures that would require sequential or near-continuous courses of antiretroviral medications (eg, multiple sex partners who rarely use condoms or injection-drug users who often share injection equipment) should not receive nPEP. In these instances, exposed persons should instead be provided with intensive risk-reduction interventions. In addition, pre-exposure prophylaxis (PrEP) should be discussed to prevent future infection.