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Postexposure management after sexual violence, Prof. Hansjakob Furrer Universitätsklinik für Infektiologie Inselspital, Bern

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Postexposure management after sexual violence

presented by: Prof. Hansjakob Furrer Universitätsklinik für Infektiologie Inselspital Bern

at: AIDSFocus Meeting
on: 10 April 2014
in: Bern

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Postexposure management after sexual violence, Prof. Hansjakob Furrer Universitätsklinik für Infektiologie Inselspital, Bern

  1. 1. Prof. Hansjakob Furrer Universitätsklinik für Infektiologie Inselspital Postexposure Management After Sexual Violence aidsfocus.ch conference, 10 April 2014, Bern
  2. 2. 23 year old women presents at the emergency department after a sexual assault, most probably rape Gyneco Emergency Lantana Police
  3. 3. Content • Risk of sexually transmitted infections • Course of HIV infection • Measures – Preemptive treatment – Targeted treatment – Vaccination – Postexposure prophylaxis – Follow-up
  4. 4. Berner Modell ♀ Gyneco Emergency ♀ Medico- Legal Dpt ♀ Dpt Infect Disease
  5. 5. Source Exposed Exposure Sexual exposure
  6. 6. Source infectious? Source Exposed Exposure
  7. 7. Source infectious? Source Exposed Exposition Sexual exposure Hepatitis B HIV Other STDs Gonorrhea, Syphilis, Chlamydia Herpes simplex, Human Papillomavirus, Hepatitis C, ….
  8. 8. Antimicrobial Treatment Symptoms Microbe Prophylaxis Preemptive Therapy Therapy  empiric  targetedInfection
  9. 9. 23 year old women presents at the emergency department after a sexual assault, most probably rape Bacterial STD Syphilis/GO/Chlamydia Either  Preemptive Therapy at time of presentation  e.g. Ceftriaxon/Azithromycin  Therapy after diagnosis  after ca 14 days (GO, Chlamydia)  Several weeks (Syphilis)
  10. 10. Source Exposed Exposure Pre-Exposure Prophylaxis Hepatitis B Vaccination Hepatitis B and HIV Post-Exposure Prophylaxis HIV Drugs
  11. 11. 2-12 weeks 2-14 years 1-6 years Seroconversion Primary HIV Infection Asymptomatic 600 106 200 104 Natural history of HIV-infection Opportunist. Diseases AIDS Death Plasma HIV RNA (copies/ml) CD4 -Lymphocytes (/µl) Anti-HIV Antibodies Organ Dysfunction Chronic Diseases Immune-activation
  12. 12. HIV Cycle Weiss, Nature 2001 Inhibitors of the Reverse Transcriptase NRTI/NNRTI
  13. 13. Organ dysfunction Immune- activation Opportunistic Infections Plasma HIV RNA (copies/ml) CD4 -Lymphocytes (/µl) Anti-HIV Antibodies 2-12 Wochen 2-14 Jahre 1-6 Jahre Primary HIV-infection asymptomatic 600 106 200 104 Verlauf der HIV-Infektion Antiretroviral Therapy Less opportunistic infections Less organ dysfunction Longer survival
  14. 14. HIV-Transmission Risk Exposure Risk ___________________________________________________ Blood Transfusion >90 % /1 ___________________________________________________ Needle exchange 0.7 % /100 Receptive anal intercourse 0.5 % (bis 3%) Percutaneous needle stick 0.3 % /1000 Receptive vaginal intercourse 0.1 % ___________________________________________________ Insertive anal intercourse 0.07 % Insertive vaginal intercourse 0.05 % /10´000 Reptive oral intercourse with ejaculation 0.01 % ___________________________________________________ Insertive oral intercourse 0.005 % /100´000 CDC. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR 2005;54 (no.RR-2): 1-20
  15. 15. First steps of infection Hladik et al, Nat Rev Immunol 2008 48-72h
  16. 16. Additional Risk Factors High HIV- viral load up to >30x Viral load undetecable for 3 months virtually no risk Other sexual transmitted infections (GO, HSV, Syph) up to 10x No Circumcision 2-3x Primary HIV-infection 10-100x Rakai-Projekt: Wawer MJ et al. JID 2005;191:4103-9. Gray RH et al. Lancet. 2007. 24;369(9562):657-66
  17. 17. HIV PCR / HIV-Antibodies (week) 0 1 2 3 4 8 12 16 20 24 Control - / - - / - - / - - / - - / - - / - - / - - / - + / - + / - + / - - / - + / + + / + + / - - / - + / + + / + + / + - / - + / + + / + + / + - / - + / + + / + + / + - / - + / + + / + + / + - / - + / + + / + + / + - / - + / + + / + + / + -/ - 12h - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - -/ - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - 36h - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - -/ - 72h - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - - / - + / + - / - - / - + / + - / - - / - + / + Otten RA, J Virology 2000;74(20):9771-5. Antiretroviral therapy as postexposure prophylaxis Does it work? Vaginal exposure in Rhesus Macaques
  18. 18. Postexposure prophylaxis: as fast as possible! PostexposureProphylaxis Hladik et al, Nat Rev Immunol 2008 48-72h
  19. 19. 23 year old women presents at the emergency department after a sexual assault, most probably rape • HBV vaccinated ? – No: vaccination • Within 48 (72h) after assault – Start immediately with 3 antiretroviral drugs PEP • 2 NRTIs + Integrase Inhibitor • 3 NRTIs • 2 NRTIs + Protease Inhibitor – Test aggressor (source)
  20. 20. HIV Seroconversion, primary HIV infection Labtests Klinische Symptome 10-20 Tage Plasma HIV RNA p24-Antigen Anti-HIV Antibodies Detection limit 10d -12w 5d 5d
  21. 21. Source infectious? Source Exposed Exposure Anti-HIV, p24 Ag, (evtl. HIV RNA) HBsAg, anti-HBc
  22. 22. Follow-up ID Source Exposed Exposure
  23. 23. 23 year old women presents at the emergency department after a sexual assault, most probably rape • HBV vaccinated ? – No: vaccination • Within 48 (72h) after assault – Start immediately with 3 antiretroviral drugs PEP • 2 NRTIs + Integrase Inhibitor • 3 NRTIs • 2 NRTIs + Protease Inhibitor – Test aggressor (source) • Stop PEP if HIV-uninfected
  24. 24. Protection of sex partners (STD, HIV, HBV) Exposure HBV: If vaccine protected no measures Exposure HIV: - PEP for 4 weeks - clinical and lab controls - serology for HIV 3 months after end of PEP Exposed
  25. 25. Berner Modell ♀ Gyneco Emergency ♀ Medico- Legal Dpt ♀ Dpt Infect Disease

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