This document provides information on post-exposure prophylaxis (PEP) for HIV. It discusses how HIV can be transmitted through contact with infectious bodily fluids, and that PEP using antiretroviral drugs can reduce the risk of transmission by around 80% if started within 72 hours of exposure. It outlines the factors that determine the risk of infection and recommendations for initial interventions, including washing any wounds, obtaining consent for HIV testing of the source person, and initiating PEP as soon as possible, preferably within two hours.

1. POST-EXPOSURE PROPHYLAXIS
(PEP)
Dr. M. MUNAWAR KHAN
BCC Coordinator
Sindh AIDS Control Program

2. Transmission
• The risk of HIV transmission is present if an
HIV-negative person comes into contact with
the blood, semen or vaginal fluids of an HIV-
positive source person. But exposure of intact
skin to HIV-contaminated body fluids (e.g.
Blood) is not sufficient to transfer the virus.

3. Transmission is possible if HIV-containing
material enters the body
• Accidental needle stick injury or incision by
surgical instruments
• Exposure of damaged skin or mucosal
membranes
• Unprotected sexual intercourse with an
infected person
• IDU sharing needle or equipment
• Transfusion of HIV-contaminated blood or
blood products

4. Transmission risk
• HIV is not a very contagious pathogen. The transmission rate
after contact is about 1:1000 to 1:100. Compared with
HIV, the transmission rate for hepatitis C is 10 times
higher, and 100 times higher for hepatitis B.
• Contact with body fluids of a patient with a high viral load
supposedly holds a higher risk of contagion than with a
suppressed viral load. Additionally, quick removal of infectious
material e.g. from damaged skin or mucosal membrane by
washing or disinfection presumably decreases the risk of an
HIV infection.
• For percutaneous contact with HIV-containing blood, an
infectiousness of 0.3 % in total is assumed.

5. Effectiveness and limitations of PEP
• Early reports on the use of AZT after
occupational needle stick injuries date from
1989. An analysis of retrospective case-control
studies shows that even prophylaxis with a
single substance after exposure reduces the
probability of an infection by approximately
80 % . The combination of multiple drugs is
supposedly even more potent.

6. When is PEP indicated
• It is important to ascertain whether the
source person has a supposed or
confirmed HIV infection. Unclear HIV status
should be clarified , the source person
should be asked for consent to perform
HIV testing. But denial of consent has to be
respected. If the source person agrees to be
tested, it should be performed immediately.

7. • For source persons with confirmed HIV
infection, the actual HIV viral load, stage of
disease, former and current HAART have to be
taken into consideration. Optimally, a
resistance analysis would also be available.
The affected person should be asked about
the first aid procedures that have already
been performed. After clarification of these
queries, the exposed person has to be
informed about possible risks of
pharmaceutical PEP

8. Potential risks of PEP
• The risks of PEP mainly concern the adverse
effects of the antiretroviral substances, most
frequently gastrointestinal symptoms such as
nausea, vomiting or diarrhea. Changes of
hematology, transaminases or creatinine are
also possible. Additionally, there have been
reports of elevated triglycerides and
cholesterol levels, and insulin resistance even
in short term use of protease inhibitors .

9. Initial interventions
• The decision about whether or not to offer PEP
should be based purely on clinical considerations of
risk (mentioned above). The provision of information
regarding PEP should be confidential, including
information about HIV testing, PEP provision and the
reasons for seeking PEP. The informed consent needs
to be obtained for the administration of PEP. The PEP
must be initiated as soon as possible after the
exposure, preferably within two hours and not later
than 72 hours; PEP is believed to be most effective if
initiated within 48 hours of exposure

10. Risk of infection
(1) type of exposure (superficial or deep injury);
(2) the amount of blood involved in the
exposure;
(3) amount of virus in patient’s blood at the time
of exposure (patient’s viral load); and,
(4) Whether PEP was taken within the
recommended time (not later than 72 hours
after exposure)

11. What to do after a needle stick
injury
(1) Wash the injured site thoroughly with soap
and water (antiseptics may be used).
(2) If as a result of a laboratory accident the skin
is broken the wound should be cleaned and
irrigated with a mild disinfectant such as
Chlorhexidine with cetrimide
(3) Administer post-exposure prophylaxis (PEP)
for HIV, based on institutional policy after
evaluation of risk.

12. Mucosal exposure
• If there is an accidental exposure of the blood
or other body fluids to mucosal surfaces (eg.
mouth, nose or eyes) flush the exposed area
with a large amount of water.
• The splashes into the eye should be flushed
using an eye wash fountain for 15-20 minutes.
PEP should be initiated as soon as possible

13. Infectious agent Post-exposure
prophylaxis
• HIV Antiretroviral therapy (2-drugs or 3-drugs
regimen)
• HBV Hepatitis B immune globulin (HBIG)
and/or hepatitis B vaccine
• HCV No vaccine or chemoprophylaxis available

14. Recommended Medication
Table Recommended antiretroviral
combinations for HIV Post-exposure
Prophylaxis
1.AZT + 3TC (Combivir.) or
2.TDF + FTC (Truvada.) or
3.TDF + 3TC (Viread.+Epivir) or
4.D4t + 3TC (Zerit.+ Epivir.)plus Nefinavir
(Viracept.)

15. THANKS