2 Common presentations Needle in the park Heterosexual sex - Vaginal OralMale to male sex - Anal OralRape - Heterosexual male to maleNeedle sharing / needle assaultOther - trauma, dermatitis, broken skin exposure
3 Assessing the risk 1. The exposure - type of sex - type of injecting equipment- nature of injury (needle gauge)- nature and volume of body fluid- time since exposure2. The source - Known +ve source VL if known; Stage of HIV- If status unknown, ? epi risk
4 Management: First Steps Clean wound (soap and water) No Caustic agentsFlush mucous membranes with salineVaginal/rectal douching not recommendedAssess tetanus hepatitis B vaccination statusOrganise pre-test counsellingRisk assessment: risk of exposure X Source riskFactors that may enhance that risk assessment
5 Current HIV seroprevalence in Australia (0.066%) Type of ExposureReceptive anal intercourseReceptive vaginal intercourseInsertive vaginal or analNeedle injuryUsing contaminated needlesMucous membraneHIV Transmission Risk< 3.0% (1 in 125 to 1 in 30)< 0.1% (1 in 2000 to 1 in 667)< 0.1% (1 in 3333 to 1 in 1111)~ 0.3% (1 in 313)~ 0.6% (1 in 149)~ 0.1% (1 in 1111)Current HIV seroprevalence in Australia (0.066%)Homosexual men 3-15%Injecting drug users ~1%Homosexual male IDU 17%HeterosexualSTD clinic attendees 0.1%Blood donor %
6 Exposure Source unknown Source Known Homosexual men Receptive anal 1 in 2223% =1 in 33.3Insertive anal0.1% x 15% =1 in 6,6660.1% =1 in 1,000Sharing needles0.6% x 15% =1 in 1,1110.6% =1 in 167Non-intact skin~ 0.6% =Mucous membrane~ 0.1% =HeterosexualReceptive vaginal0.1% x 0.1% =1 in a million~ 0.1%
8 Other Risk Factors and Balancing Risk ? Patient viral load, treatment history? Presence of STI in source or exposed person? Ulcerative or inflammatory oral disease if oral sex? Volume of blood if needle exposure1 in 6 million for death from bee sting per year1 in 5 million for childhood kidnap per year1 in 2 million die by lightning strike each year1 in 800 die due to smoking-related illnesses
9 Management: What needs to be discussed Pre-test counselling (may be delayed)Risk carefully explainedHIV pep is NOT a proven therapy4 week therapy (can be difficult)Protection for others (condom, needle sharing, breast feeding, blood donation, safe work practices)Side effects of drugs (don’t confuse seroconversion)Risks in pregnancyIt is the choice of the patient and can stop anytimeNeed for follow-upCounselling and support ! ! ! ! !
10 Drug therapy Consider: Unprotected receptive or insertive anal intercourseSharing needles and syringesUnprotected receptive or insertive vaginal sexMucous membrane or non-intact skin exposure to HIV-positive bloodLesser risk, but considerUnprotected receptive fellatio if source known positive AND recipientMucous membrane, non-intact skin exposure to HIV-infected secretionsALSO, source should be known positive, or at epidemiological high riskAlso, consider whether presents within 72 hours
11 The drugs: which one 2 drugs most commonly: combivir Factor in drug history of sourceALWAYS consult when prescribing3 drugs if known Positive source AND advanced disease High viral load Has resistant virusNever use nevirapine
12 Document For exposed individual Nature, time of exposure, factors in exposure, time seenRecent HIV testing, previous exposures, pep useCurrent STIs; history of other STIs; Hep B,C historyPregnant? breast feeding?Significant medical disease, medicationDiscussion around PEP understanding, risk/benefit, treatment decision and what was recommendedConsent for baseline testing after pre-test counseling: HIV, pregnancy, hepatitis B and C, blood count, LFTFor source individualHIV stage, CD4 count, viral load, retroviral history, resistance testshepatitis status, Hepatitis B infectivity, hepatitis C Viral loadSTI history: present and past infections
13 Management: what else to consider TetanusHepatitis BHepatitis COther STIsSepsis (Staphylococcal infection in IDU)
14 Management: Hepatitis B If ever PROVEN immune to hepatitis B by vaccine or infection, no need for further therapyIf non-immune, commence vaccination +/- HBIg within 72hours.If previously completed full vaccination >90% protectedsAg positive; eAg, DNA positive: 30-40%sAg pos; eAg, DNA neg: < 6%
15 Hepatitis C Risks High prevalence in drug users If sero-positive, risk for needlestick 1.8%If RNA positive, risk of needlestick 10%Potential benefit of early treatment during seroconversionFollow up testing via serology +/- LFT, viral assessment
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