1. HIV post exposure prophylaxis on your medical elective Dr Sarah Barrett Consultant Sexual Health and HIV Medicine Birmingham Heartlands Hospital

2. PEP

3. Post Exposure Prophylaxis (PEP) is a course of antiretrovirals that can stop you becoming HIV positive after you've been exposed to the virus.

4. Introduction What is high risk? – Countries – Injuries What do I do if I get a needlestick? What do I need to know about the drugs? – Timing – Side effects – Interactions – Cost! How do I get the drugs – PEP clinic – Reselling of drugs Questions

5. Increased risk overseas... ‘Of the 14 ‘possible’ occupationally acquired HIV infections reported in the UK, 13 had worked in areas of high HIV prevalence and were probably infected abroad’

6. Increased risk overseas... ‘Of the 14 ‘possible’ occupationally acquired HIV infections reported in the UK, 13 had worked in areas of high HIV prevalence and were probably infected abroad’ why?

7. Increased risk overseas... ‘Of the 14 ‘possible’ occupationally acquired HIV infections reported in the UK, 13 had worked in areas of high HIV prevalence and were probably infected abroad’ why? Higher prevalence of HIV infection lack of standard infection control measures poor or inadequate equipment leading to increased risk of exposure Relative inexperience/lack of technical skills of students No Post exposure prophylaxis

8. Which countries are high risk?

10. Cartogram of HIV prevalence

11. 38%

12. Cartogram of HIV prevalence

14. What is high risk? Risk of acquiring HIV from occupational exposure is LOW – Needle stick 3 in 1000 – Mucocutaneous 1 in 1000 – Intact skin, urine, vomit, saliva, faeces – negligible

15. What is high risk? Risk of acquiring HIV from occupational exposure is LOW – Needle stick 3 in 1000 – Mucocutaneous 1 in 1000 – Intact skin, urine, vomit, saliva, faeces – negligible – Receptive vaginal intercourse 1 in 500 – Receptive anal intercourse 1 in 30

16. What is high risk? Increased risk if – Deep injury – Visible blood – Injury with a needle which had been placed in a source patient’s artery or vein. – Terminal HIV-related illness in the source patient.

17. Prevention

18. Wear gloves Do NOT put yourself in risky situations Goggles Safe disposal of needles Wear a condom (!)

19. What should you do if you get a needlestick?

20. Following any exposure Wash liberally with soap and water, don’t scrub! Antiseptics and skin washes should not be used Encouraged gentle bleeding of puncture wounds Irrigate exposed mucous membranes copiously with water Report injury to Dr in charge – They need to assess the source patient

21. PEP Viral dissemination does not occur immediately leaves a window of opportunity during which PEP may be beneficial Most efficacious if started within the hour Definitely within 72hours If in doubt, take it and stop after further information obtained

22. The drugs...

23. The drugs Two Kaletra tablets (protease inhibitor) bd One Truvada tablet (Tenofovir and FTC) od No food restrictions PEP pack can be stored at room temperature Starter pack contains 4 days Should continue for 28 days (enough given to source more locally or come home) Benefits should outweigh risks of drugs

24. Problems with the drugs... Side effects – Commonly gastrointestinal (e.g. Nausea and diarrhoea) beware dehydration – Dizziness and headache. – Skin rash Interactions – www.hiv-druginteractions.org

25. The good news is.... Antiretroviral medication has become more widely available in high HIV prevalence countries Prior to departure make enquiries whether PEP protocols are established in your elective centre If PEP is not available consider taking a PEP starter pack

26. The Pre-elective PEP clinic You will receive an email containing details about 2 months before departure Risk assessed Baseline HIV test (+ ?confidential STI screen) Written information given Pack with gloves/needles and condoms Prescription for 4 days of drugs if appropriate £99 (cost of drugs only)

27. Reselling of drugs... NOT encouraged! Trust the person you are buying from Ensure drugs are in date Ensure attend PEP clinic – Baseline HIV test – Instructions – Medical kit