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Transmission of HIV through occupational exposure in healthcare personnel is rare. Consider the seroconversion window period if the source patient had a recent last weeks high risk HIV exposure, or if they have s suggestive of an acute viral syndrome e. In non-occupational sexual exposure settings, source patient should be tested if available, but often is not, so a risk assessment should be performed. There is no evidence of PEP efficacy when initiated past 72 hours.

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In view of this critical window for intervention, it is often advisable to initiate PEP immediately even if questions remain, re-evaluating over the next few days and discontinuing PEP if indicated. PEP should be discontinued if a source patient of unknown serostatus is later found not to be HIV infected. Risk of transmission of HIV from percutaneous exposure is estimated to be about 0.

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Factors that increase risk of transmission include exposure through a visibly bloody device odds ratio [OR], 6. Risk of transmission from splashing-type mucous membrane e. For HIV transmission, substances or fluids that are considered infectious include blood, plasma, tissue, semen, vaginal secretions, and pus, as well as cerebrospinal, amniotic, pericardial, peritoneal, pleural, and synovial fluids.

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Unless visibly bloody, substances generally considered non infectious include urine, feces, nasal secretions, gastric fluid, sputum, tears, sweat, and vomitus. Non bloody saliva from bites, while generally felt to be minimally or non infectious can rarely be associated with HIV transmission.

Post-exposure prophylaxis for hiv infection

Risk of HIV infection from non-occupational exposure varies widely based on the nature of the exposure. The estimated risk of transmission associated with sharing needles for injection-drug use is approximately 0. Oral sexual activity seems to be associated with a small but real risk based on case reports of HIV infection in persons in whom the only reported risk factor was oral intercourse. In addition to type of exposure, risk of sexual HIV transmission is modified by numerous factors, among them presence or absence of active genital ulcers, cervical or anal dysplasia, male circumcision, and quantity of genital secretion HIV RNA.

Most but not all individuals with an undetectable plasma viral load also have an undetectable genital tract viral load. Although suppressive antiretroviral therapy ART reduces the likelihood of HIV transmission, an undetectable plasma viral load does not mean an individual is noninfectious.

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Risk assessments are used to help guide decisions on a case by case basis see Figure 1. Patients should have symptom directed testing as needed for possible toxic side effects, typically including creatinine, electrolytes, liver function tests, and CBC with differential. Patients who have been exposed recently within 1 week to an HBsAg-positive source patient and who are negative for Hepatitis B sAb should considered for treatment with Hepatitis B immune globulin.

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Note: this will give the patient a positive Hepatitis B Ab test but does not imply they are infected. These drugs suppress Hepatitis B replication and acute hepatitis flares may result when PEP is withdrawn. Extended transaminase monitoring, alternative PEP, and hepatologist consultation may be indicated. Like Hepatitis B, Hepatitis C can be transmitted both percutaneously and sexually especially among men who have sex with men.

Early Hepatitis C treatment may reduce possibility of chronic disease. Screening and treatment as needed for syphilis, gonorrhea, and chlamydial infections should also be performed in patients who seek care after sexual exposure.

A multi-us city assessment of awareness and uptake of pre-exposure prophylaxis (prep) for hiv prevention among black men and transgender women who have sex with men

Hepatitis, lactic acidosis, and toxic skin rashes are rare but potentially life threatening and typically require drug cessation. Regular follow up, even weekly, in person, byor by telephone has been recommended to monitor toxicity and adherence. The goals for post-exposure management are to prevent HIV transmission while avoiding unnecessary PEP and PEP toxicity, and provide counseling and follow-up for exposed individuals.

Generally, it may be preferable to start a basic 2 drug regimen awaiting consultation, rather than delay PEP. Expert consultation may be advisable in these cases.

Prevention

Resistance testing of the source virus at the time of an exposure is impractical because the will not be available in time to influence the choice of the initial PEP regimen. A small of healthcare worker transmissions have be documented to occur when the source HIV strain was resistant to the agents used in PEP. Expert consultation is advised in this instance to help select drugs the virus is likely to be sensitive to.

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Note that no data suggest that modification of a PEP regimen after resistance testing become available usually 1—2 weeks improves efficacy of PEP. Where the HIV serostatus of the source individual is unknown, PEP should be considered based on exposure risk as defined in Table I and Table II in selected high-risk source populations among whom the seroprevalence of HIV infection is considered to be sufficient to justify the potential toxicity and cost of treatment. The PEP regimen should take into potential drug interactions with concomitant medications.

Hiv non-occupational post exposure prophylaxis in nigeria: a systematic review of research evidence and practice

Non-nucleoside Reverse Transcriptase Inhibitors also have numerous drug-drug interactions. It is essential to review the patients other medications and updated PEP agent package inserts for drug-drug interactions.

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Expert consultation with an HIV specialist or pharmacist is recommended when potential for such interactions are suspected. Local antiretroviral options for PEP may be limited or of questionable authenticity. Delayed e. Unknown source e. Known or suspected pregnancy in the exposed person use of optimal PEP regimens is not precluded.

Toxicity of the initial PEP regimen. Adverse symptoms e. Cases had ificantly lower odds of having taken zidovudine after exposure compared to controls OR 0.

Hiv postexposure prophylaxis (pep), nonoccupational (npep)

A retrospective analysis of administration of non-occupational HIV PEP in a single Swiss center where tracing and testing of source patients was carried out systematically between and [23]. Additional indirect evidence of PEP efficacy include macaque studies that show superior efficacy when PEP is given with 36 hours as compared to 72 hours post simian immunodeficiency virus SIV exposure.

Tenofovir-Emtricitabine has been shown to be effective as pre-exposure prophylaxis in men who have sex with men. Optimal duration of PEP has not been defined by controlled studies, although PEP is generally continued for 28 days, as macaque models have demonstrated incomplete protection when shorter courses PEP courses are employed following intravenous SIV challenge.

There are no comparative efficacy studies of the various drugs, or 2 vs. Discontinuation rates appear to be similar.

1. background and introduction

Tenofovir-containing regimens are generally better tolerated in PEP but should not be used when renal insufficiency is present. It represents a balance of risk and benefit for each individual patient. At a public health level, the costs of such treatment must be balanced against the risk of transmission associated with a given exposure.

Few studies and fewer still randomized trials comparing various regimens for PEP exist. The optimal of antiretroviral agents to be used in a PEP regimen remains uncertain as the quantity and genetic diversity of infectious HIV typically delivered during all but the worst exposures is several orders of magnitude less that that seen when treating a patient with HIV. Predictors for recommendations outside of the guidelines included certain source-person characteristics such as current use of specific antiretroviral drugs, prior antiretroviral drug exposure, antiretroviral drug resistance, and clinical status.

Because of their mechanisms of action, raltegravir, the first HIV integrase inhibitor, and maraviroc, the first C-C chemokine receptor 5—receptor antagonist, are both attractive options for prevention. In contrast to protease inhibitors, these drugs work before HIV latency is established, which is theoretically desirable.

Experience with these agents for PEP is limited to isolated case reports and small case series in which their use appeared to be safe. Both tenofovir and emtricitabine have been shown to penetrate the genital tract well in animal models, reaching peak levels within 24 h of dosing, characteristics which may be advantageous for PEP in these women seeking sex in pep texas. Both efavirenz and lopinavir had ificantly lower women seeking sex in pep texas in female genital secretions than tenofovir and lamivudine.

Raltegravir and maraviroc have also been shown to achieve high levels in the genital tract. Substantial was defined as exposure of vagina, rectum, eye, mouth, or other mucous membrane, non-intact skin, or percutaneous contact, WITH blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood WHEN the source is known to be HIV-infected.

Active source tracing with rapid HIV tests should be pursued when feasible as this strategy allows nPEP to be avoided or terminated early in many cases. Regardless if nPEP is employed, the healthcare worker should view these encounters as a prevention counseling opportunity.

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It may be difficult logistically for emergency departments or urgent care centers to obtain and initiate nPEP, or monitor the course of treatment. Safety and feasibility of nPEP programs have been demonstrated in several U. S and European metropolitan areas. While nPEP is routinely offered in cases of sexual assault and often offered with isolated high risk exposures, its role with individuals who continue to engage in high risk behavior is particularly hard to define. The recent finding that pre-exposure prophylaxis with tenofovir-emtricitabine was shown to be effective in preventing HIV transmission in MSM will certainly become part of this deliberation.

As long as the patient and healthcare provider are aware of the risks and benefits of PEP, initiating PEP even when there appears to be only minimal risk from the exposure may have the added value in reducing the anxiety typical in these settings.

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While costly, few serious toxicities from PEP have been reported. It is worth noting that this approach may be effective, as no new cases of transmission via occupational exposures have been reported in more than 5 years. Certainly, other factors leading to a safer work environment e. Current international guidelines all recommend the use of PEP for a duration of 28 days following an occupational exposure from with an individual known or likely to be HIV seropositive. Generally, PEP is recommended if it can be given within 72 hours of exposure, however, the European guidelines recommend a limit of 48 hours.

The European guidelines recommend using a three antiretroviral drug combination for PEP in all cases.