Therapeutics II - HIV 3 (PEP, PREP, OI Prevention)

Signs and symptoms of HIV if CD4 200-500

1. Bacterial infections (pneumococcal pneumonia, sinusitis) 2. Kaposi's Sarcoma 3. Vaginal candidiasis 4. IMT (ITP)

When to test for HIV if on PrEP?

1. Baseline 2. 3 months

Infectious exposures?

1. Blood 2. Visible body fluids 3. Tissue

Toxoplasma gondii encephalitis 1. Indication for prophylaxis 2. Treatment

1. CD4 <100 2. Bactrim (TMP/SMX)

Pneymocystitis jiroveci Penumonia (PCP) 1. Indication for prophylaxis 2. Treatment

1. CD4 <200 2. Bactrim (TMP/SMX)

Disseminated Mycobacterium avium complex (MAC) 1. Indication for prophylaxis? 2. Treatment?

1. CD4 <50 2. Azithromycin (Preferred) OR 3. Clarithromycin (more CYP interactions)

Situations when Expert consultation is advised when starting PEP?

1. Delayed exposure report (>72 hours) 2. Unknown source (needle in sharps container) 3. Known or suspected pregnancy 4. Known or suspected ARV resistance in source 5. Serious medical illness in exposed person 6. Toxicity occurring in person taking PEP regimen

Signs and symptoms of HIV if CD4 < 50

1. Disseminated MAC 2. CMV retinitis 3. HIV associated wasting 4. Neruopathy 5. Encephalopathy 6. Lymphoma

What is PrEP?

1. HIV-uninfected person takes ART prior to potential HIV exposure 2. Presence of medications in bloodstream or tissues decreases risk that HIV may be able to establish infection

Azithromycin (clarithromycin) is used to prevent what OI?

1. MAC

Signs and symptoms of HIV if CD4 >500

1. Most illnesses similar to non-HIV patients 2. Some increased risk of bacterial infections

Is the risk of HIV transmission high with Occupational Exposure?

1. NO - relatively low 2. Hep B and Hep C risk is much higher 3. Hep C is scary!

Prophylactic Bactrim is used to prevent what OI?

1. PC 2. Toxoplasma gondii encephalitis

Occupational exposure in healthcare personnel?

1. People in healthcare who have potential to exposure to infected materials 2. Includes: ---EMS ---Nurses, CNAs ---Physician ---Pharmacist ---Maintenance ---Housekeeping, etc.

What vaccinations should be given to help reduce OIs?

1. Pneumonia 2. Influenza 3. Hep A 4. Hep B 5. VZV 6. HPV

What is PEP?

1. Post-exposure prophylaxis 2. Using ART to prevent HIV transmission AFTER an exposure to a known HIV-infected source or where there is reasonable suspicion of HIV infection in the source.

Approaches to management of OIs in HIV infections?

1. Primary Prevention - no prior infection 2. Secondary Prevention - after OI to prevent recurrence 3. Vaccinations - Pneumonia, Hep A, B, VZV, HPV 4. Treatment for OI 5. ART - BEST PREVENTION

Efficacy of PrEP?

1. Risk reduction by 75% in heterosexual serodiscordant couples 2. 44-75% effective across all studies

Not considered potentially infectious unless visibly bloody?

1. Saliva 2. Vomit 3. Feces 4. Nasal secretions and sputum 5. Urine

Potentially infectious?

1. Semen and vaginal secretions 2. CSF 3. Synovial fluid 4. Pleural fluid 5. Peritoneal fluid 6. Pericardial fluid 7. Amniotic fluid

Occupational vs. Non-Occupational?

1. Separate guidelines for PEP and nPEP 2. Non-occupational = IV drug use, rape, etc.

Timing of PEP?

1. Should be started ASAP - ideally w/in hours of exposure 2. PEP less effective if started more than 72 hours after exposure

Signs and symptoms of HIV if CD4 50-200

1. Thrush 2. Oral hairy leukopenia 3. OIs ---PCP ---cryptococcal meningitis ---toxoplasmosis

When is PrEP recommended?

1. Uninfected people at high risk of infection and who may engage in high-risk activity with HIV infected persons. 2. High risk sexual activity, IV drug use 3. Serodiscordant couples 4. Only in patients who are confirmed to be HIV negative

Factors associated with increased risk of occupational exposure?

1. Visible contamination with blood 2. Needlestick directly into vein or artery 3. Hollow-bore vs. solid device/needle 4. Deep tissue injury (deep needle stick) 5. Source patient with advanced AIDS or high viral load 6. Spray with CSF

What to do if possible exposure?

1. Wash first 2. Detailed report of what happened 3. If high risk, get baseline labs from exposed person 4. Labs from source if possible

What drives PrEP efficacy?

Adherence

For patients receiving prophylaxis, when do most OIs start to occur?

CD4 count <100

Dosing of Truvada for PrEP?

Daily

****Recommendations for PEP 2013***

Raltegravir PLUS Tenofovir/Emitricitabine x 28 days

What is the only FDA approved drug regimen for PrEP?

Truvada (Tenofovir + Emitricitabine)