Post exposure Prophylaxis, occupational

Z20.6 + Z20.5 + (Z57.8+X58.92+Z29.8)

• Description
• General Measures
• Medicine Treatment
• Referral

DESCRIPTION

Post exposure prophylaxis may prevent the risk of acquiring HIV and hepatitis B following a significan occupational exposure to infectious material from a patient (includes blood, CSF, semen, vaginal secretions and synovial/pleural/ pericardial/ peritoneal/amniotic fluid).

The risk of acquiring HIV following occupational exposure is estimated at 0.3%. There is a higher risk when:

• the injury is deep or
• involves a hollow needle or
• if the source patient is more infectious, e.g.: WHO stage 4 defining illness, or known to have a high HIV viral load, i.e. >100 000 copies/mL, seroconversion illness.

GENERAL MEASURES

• Where the source patient is on ARVs or has been on ARVs, initiate prophylaxis and seek expert opinion. An extra blood sample (unclotted, EDTA) of the source patient should be stored in case of need for further viral testing.
• Other blood borne infections that can be transmitted include hepatitis B, hepatitis C and syphilis. Test all source patients (see monitoring table).
• Offer comprehensive and confidential pre-test HIV counselling.
• Advise HCW about the need to take precautions, e.g. condom use, (for 4 months), to prevent HIV and HBV transmission to sexual partners.

• Document occupational exposures adequately for possible subsequent compensation.

INVESTIGATIONS

**If occupational exposure
*** If sexual exposure

LoEIII [28]

MEDICINE TREATMENT

1. Prevent HIV: Z20.6 + (Z57.8+X58.92+Z29.8)

• Initiate HIV PEP immediately after the injury - within 72 hours. Do not wait for the confirmatory test results on the source patient and health care worker.
• If higher risk exposure (defined above) consider initiation of treatment beyond 72 hours, as the risks of prophylaxis in this setting may outweigh the benefits. Avoid initiating PEP beyond 7 days after exposure.

Note: HIV PEP is not indicated if:

• HCW exposed to body fluids which carry no risk of infection, e.g. vomitus, urine, faeces or saliva.
• HCW is HIV-infected. Stop PEP if HIV test of the health care worker is positive at the time of the injury.
• The source is HIV sero-negative unless there are features suggesting sero-conversion illness.
  • Continue prophylaxis until the results of additional tests are available.
  • These cases should be discussed with virologists.

When PEP is indicated, the following regimen is recommended:

• Tenofovir (TDF), oral, 300 mg daily for 4 weeks (provided baseline eGFR is > 50 mL/minute).

and

• Lamivudine (3TC), oral, 300 mg daily for 4 weeks.

and

• Dolutegravir (DTG), oral 50 mg once daily for 4 weeks.

Note: Administer a FDC wherever possible.

In WOCP, pregnant women <6 weeks gestation, or where DTG is not tolerated:

• Tenofovir (TDF), oral, 300 mg daily for 4 weeks (provided baseline eGFR is >50 mL/minute).

and

• Emtricitabine (FTC), oral, 200 mg daily for 4 weeks.

and

• Atazanavir/ritonavir (ATV/r) 300/100 mg, daily for 4 weeks.

OR

• Lopinavir/ritonavir (LPV/r) 200/50 mg, 2 tablets 12 hourly for 4 weeks.

Note: Administor a FDC wherever possible.

If tenofovir is contraindicated or if source patient is known to be failing a tenofovir based regimen, replace tenofovir and emtricitabine with:

• Zidovudine (AZT), oral, 300 mg 12 hourly for 4 weeks.

and

• Lamivudine (3TC), oral, 150 mg 12 hourly for 4 weeks.
• PEP is generally not well tolerated. Adverse effects occur in about half of cases and therapy is discontinued in about a third. Efavirenz (EFZ) is not recommended as it is very poorly tolerated in PEP.
• AZT often causes nausea and headache. If AZT is not tolerated, switch to TDF (check baseline eGFR as above).
• LPV/r often causes diarrhoea. If LPV/r is not tolerated switch to ATV/r. ATV/r often causes unconjugated jaundice, which is benign but may not be tolerated, in which case switch to lopinavir/ritonavir.
• When the source patient is known to be failing ART, modify the PEP regimen:
  • If the patient is on AZT , use TDF.
  • If the patient is on TDF then use AZT
  • Patients failing 2nd line ART usually have no resistance to protease inhibitors, so lopinavir/ritonavir should still be effective, but consultation with a virologist or infectious diseases physician is recommended for advice on which ARVs to use for PEP in this setting.

Note: Adverse effects of PEP:

• PEP is generally not well tolerated. Adverse effects occur in about half of cases and therapy is discontinued in about a third.
• TDF is contra-indicated in renal disease or with concomitant use of nephrotoxic medicines, e.g. aminoglycosides (check baseline creatinine clearance). Where TDF is contraindicated, switch to AZT. If AZT is not tolerated, consult or refer for further management.
• Give ATV/r as first choice as LPV/r frequently causes gastrointestinal side effects. ATV/r may commonly cause jaundice (i.e. unconjugated hyperbilirubinaemia without hepatitis) which is harmless.

When the source patient is known to be failing ART, modify the PEP regimen and seek expert opinion:

• If the patient is on AZT or stavudine then TDF should be used.
• If the patient is on TDF then AZT should be used
• If the patient is on efavirenz or nevirapine then ATV/r or LPV/r should be used.

Patients failing second line ART almost always have no resistance to protease inhibitors, so ATV/r or LPV/r should still be effective,

Consultation with a virologist or infectious diseases physician is recommended for advice on which antiretroviral medicines to use for PEP.

1. Prevent hepatitis B
   Decide on what treatment to give the exposed person according to the vaccination status (and antibody response) of the exposed person, as well as the HBsAg results of the source patient, if known.

PEP following hepatitis B exposure: Z20.5 + (Z57.8+X58.92+Z29.8)

* Refer to secondary level of care for HBIG, IM. HBIG to be given as soon as possible, preferably within 24-72 hours after exposure (or within 7 days).

LoEIII [29]

# If the delay in obtaining HBsAb results is more than 24 hours, initiate treatment as for vaccinated AND HBsAb< 10 units/mL.

Note: For health care workers: repeat HBsAb 1 – 2 months after the last vaccine dose, to ensure adequate immune response (i.e. HBsAb ≥ 10 units/mL).

LoEIII [30]

REFERRAL

Note: Refer if there are inadequate resources with regard to:

• counselling
• laboratory for testing
• medico-legal examination
• medicine treatment