Download View

Case Conference: 30 yo man
with a potentially high risk
HIV exposure
November 23, 2005
James M Sosman, MD
E001248D 1
Case
• ID: GS is a 30 yo man who presents
• CC: high risk sexual exposure over the past weekend
• HPI: GS contacted the clinic Monday PM and spoke
with my nurse via phone. He stated that he may have
experienced a high risk sexual exposure the past
weekend and wanted to know what he should do. My
nurse got him in to see me in clinic that PM.
E001248D 2
Case
• HPI (cont): GS states that he had unprotected
receptive anal intercourse with a man he met
at a bar Saturday night. He did not believe that
the man ejaculated into him. GS stated that he
usually uses condoms but had been drinking
that evening and used “bad judgment”. GS did
not know his sexual partner but had heard
“rumors” that he might be HIV +.
E001248D 3
Case
• PMHx:
– No history of STD or genital warts
– No surgical or medical problems
– Denies a history or hemorrhoids or anal fissures
– GS states he took a home HIV test last month which
was negative
• NKAD
• Medications: none
E001248D 4
Case
• SHx:
– Worked as medical administrator
– Lives alone, occasional ETOH no IDU no illicit drug
use
– Considers himself homosexual
• ROS: denies urethral, anal or oral discharge, pain or
trauma/bleeding
E001248D 5
Case
• PE: GS was somewhat anxious.
• VS: 125/80, 88, 18, 96.8 wt 210lbs with clothes/shoes
– Skin: no lesions, no tattoos, no warts
– HEENT: no oropharyngial lesions with good
dentition
– Back: no CVA or spinal tenderness
– GU: normal penis and testes without lesions or
penile discharge
– Rectal: no perirectal lesions or anal tenderness.
Prostate smooth and nontender
E001248D 6
Case
• GS reports a potential high risk sexual
exposure. What should we do?
E001248D 7
Case
• Should we provide non-occupational post
exposure prophylaxis with antiretroviral
medication (nPEP)?
E001248D 8
Estimated per-act risk for acquisition of HIV, by
exposure route*
E001248D 9
Case
• Assessment of GS’s sexual exposure risk:
– Anal receptive intercourse from source with
unknown HIV status
– < 72 hours since exposure
• Should we offer nPEP?
E001248D 10
Biologic Plausibility of PEP
• Animal Models
– Macaque SIV studies demonstrated efficacy of PMPA (tenofovir) in
blocking IV exposure to SIV if administered within 24hours and
continued for 28 days
• Postnatal Prophylaxis
– Abbreviated regimens of ART for reducing mother to child HIV
transmission have been extensively studied. Women receiving even a
single dose of nevirapine at the beginning of labor and then one does
to the neonate within 72 hours of delivery had a 50% reduction in
transmission compared with those receiving AZT in a similar manner
• PEP for Healthcare Workers
– AZT PEP for occupational needle-sticks can reduce the risk of HIV
transmission by 81%
E001248D 11
Risk Factors for HIV Transmission After Percutaneous
Exposure to HIV-Infected Blood: CDC Case-Control
Study*
Risk Factor
Deep injury
Visible blood on device
Procedure involving needle
placed in artery or vein
Terminal illness in source patient
Postexposure use of AZT
Adjusted OR ratio
(95% CI)
15 (6.0-41)
6.2 (2.2-21)
4.3 (1.7-12)
5.6 (2.0-16)
0.19 (0.06-0.52)
*Cardo et al., New Engl J Med 1997;337:1485-90.
E001248D 12
Mixed Results for non-occupational PEP (nPEP)
• Only observational studies and case reports
• Sexual assault survivors in Brazil who sought care within 72hrs
were treated for 28 days with AZT/3TC. Women assessed after
72hrs were not treated. Of 180 treated, none seroconverted but of
145 not treated, 4 (2.7%) seroconverted.
• Feasibility trial of nPEP in San Francisco, 401 persons with sexual
or IDU exposure were enrolled. No seroconversions were
observed in any group; those treated 28 days, treated < 28 days,
or those not treated.
• Case report of a single patient receiving HIV tainted transfusion,
started PEP 1wk later and continued for 9 months without
seroconversion
E001248D 13
CDC Guidelines for nPEP
• January 2005, CDC published guidelines
regarding non-occupational HIV PEP
• nPEP guidelines may serve as a national
standard similar to PEP for HIV exposure to
HCWs
E001248D 14
CDC Guidelines for nPEP
• non-occupational HIV exposure
– any direct mucosal, percutaneous, or intravenous
contact with potentially infectious body fluids that
occurs outside perinatal or occupational situations
(eg, health care, sanitation, public safety, or laboratory
employment).
• Potentially Infectious Body Fluids
– blood, semen, vaginal secretions, rectal secretions,
breast milk, or other body fluid that is contaminated
with visible blood
E001248D 15
Algorithm for evaluation and treatment of possible
non-occupational HIV exposures
E001248D 16
Algorithm for evaluation and treatment of possible
non-occupational HIV exposures
E001248D 17
Antiretroviral regimens for non-occupational
post-exposure prophylaxis of HIV infection
E001248D 18
Case
• GS was willing to take nPEP and reduce his risk of
future sexual exposures:
– Started Truvada (Tenofovir/emtracidabine) qD for
28 days
– Baseline labs
– GS could not confirm HIV status of sexual
contact
E001248D 19
Recommended HIV post-exposure prophylaxis
(PEP) for percutaneous injuries in HCWs
E001248D 20
Post-Exposure Prophylaxis(PEP) Among
HCWs for HIV Prevention
• Wang SA, et al. Infect Contr Hosp Epidemiol
2000;21:780
• Presented findings from the PEP Registry (CDC,
FDA, HRSA, NIH)
• 492 enrolled HCWs with occupational exposure to
HIV from October 1996 thru December 1998
– Median time from exposure to initial PEP was
1.75 hours
– No seroconversions at 6 wks for 449 HCWs
– Adverse side effects noted in 76%
E001248D 21
Case
• Offering a two-drug regimen is a viable option,
primarily because the benefit of completing a full
course of this regimen exceeds the benefit of
adding the third agent and risking non-completion
because of side-effects
E001248D 22
Case
• GS’s W/U included:
– HIV antibody negative
– RPR negative
– Urine for GC and CT via LCX negative
– Hepatitis A and B serologies immune
– Hepatitis C antibody negative
E001248D 23
Recommended laboratory evaluation for nonoccupational post-exposure prophylaxis (nPEP) of HIV
infection
• Test
Baseline
4-6wks
• HIV Ab
X
X
• STD screen
X
X
• HBV serology
X
X
• HCV serology
X
• CBC/LFTs/Cr
X
• Pregnancy test
X
E001248D 24
3 months
X
X
X
X
X
during nPEP
6months
X
Case
• GS tolerated the medication without difficulty. He
missed no dosed in the 28 day treatment:
– 6 week F/U labs included HIV(-), STD and RPR
negative
• GS is employing safer sexual practices
E001248D 25
HIV PEP for Sexual Exposure in US ERs
(Merchant, RC Am J Emerg Med 21:4; 2003)
Circumstances for prescribing PEP
EXPOSURE
RISK
PEP OFFERED
Needle Stick
Unknown
79%
High risk or HIV +
95-98%
Low risk
41%
Unknown
73%
High risk or HIV +
93-96%
Low risk
44%
Unknown
45%
High risk or HIV +
84-89%
Low risk
22%
Sexual Exposure
Consensual Sex
E001248D 26
Resources for evaluation and treatment of possible
non-occupational HIV exposures
PEPline at
http://www.ucsf.edu/hivcntr/Hotlines/
PEPline: telephone 888-448-4911
CDC (for reporting HIV infections in HCW and
failures of PEP) at telephone 800-893-0485
E001248D 27