NON-OCCUPATIONAL POST EXPOSURE PROPHYLAXIS IN HIV PREVENTION. Jason E. Vercher, PA-C, AAHIVM
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1 NON-OCCUPATIONAL POST EXPOSURE PROPHYLAXIS IN HIV PREVENTION Jason E. Vercher, PA-C, AAHIVM
2 Disclosures No disclosures to report
3 Learning Objectives q Identify Individuals who would benefit from non-occupational post exposure prophylaxis. q Develop an appropriate npep regimen. q Implement a follow up and preventative education plan for your npep patient.
4 HIV/AIDS Epidemiology Update
5 Major Disparities Exist in the U.S. HIV Epidemic AK 8.9 HI 7.1 Percent Undiagnosed Among Persons Living with HIV Infection, by Jurisdiction, 2012 United States CA * * 17.3* Nationally, 87% of Americans living with HIV knew their HIV status in 2012 but this percentage varied substantially across states. People living with HIV in the South (and some states in the Midwest) were less likely to be aware of their infection than those living in other U.S. regions * (VT) 5.0* 7.5 (NH) (MA) 11.2 (RI) 9.6 (CT) (NJ) (DE) 18.7 (MD) 10.6 (DC) Percentage of HIVinfected persons who are undiagnosed < McCray E. National HIV Prevention Conference 2015; Atlanta,GA. Plenary session. U.S. Centers for Disease Control and Prevention (CDC). Available at: Accessed
6 Death Rate Among People with Diagnosed HIV, Aged >13 Years, By State, 2012 CA Rates per 1,000 population Alaska 7.9 to to to to 30.8 Hawaii Across the United States, Southern states bear the greatest burden of HIV infection, illness, and death. Southern states account for an estimated 44% of all HIV-infected persons, and only 37% of the U.S. population. People with HIV in some Southern states have death rates that are 3 times higher compared with those in some other states. McCray E. National HIV Prevention Conference 2015; Atlanta, GA. Plenary session. U.S. Centers for Disease Control and Prevention (CDC). Trends in HIV Diagnoses, December 2015.
7 CDC: New HIV Diagnoses by Race/Ethnicity and Transmission Category, HIV-infected Persons, n 25,000 20,000 15,000 10,000 5,000 New HIV Diagnoses Race/Ethnicity, Native American Asian American Black/African American Hispanic/Latino Native Hawaiian/Other Pacific Islander African Americans (AA) continue to be disproportionately affected by HIV. White Multiple races While AA represent about 13 % of the U.S. population, they accounted for 44% of all HIV diagnoses in Similarly, Latino men and women accounted for 23% of all new HIV diagnoses, while only representing 17% of the population. U.S. Centers for Disease Control and Prevention (CDC). Trends in HIV Diagnoses, December New HIV Diagnoses by Transmission Category, ,000 25,000 20,000 15,000 10,000 5, MSM Heterosexual IDU MSM/IDU The annual number of HIV diagnoses in the United States declined by 19% in the past decade ( ) Steep declines in: Heterosexuals (35%) Inject drug users (63%).
8 Estimated New HIV Infections in the US, by Age, 2014 Estimated New HIV infections, n % 7,868 7,870 6,026 4,662 4,196 4,021 3,242 1, ,166 1, < >65 17 % Persons <25 and >50 years old comprised almost 40% of new HIV infections in Centers for Disease Control and Prevention. HIV Surveillance Report, 2014; vol Published November Accessed April 13, 2016.
9 Risk of Transmission of HIV 4 Distinct Groups in npep studies. Men who have sex with men (MSM) IV Drug Users (IVDU) Heterosexual men and women (MSW/ WSM) Other routes of exposure (eg, human bites)
10 HIV Life Cycle
11
12 Course of Acute HIV infection
13 Sexual Exposures Risk by Encounter Type MSM Receptive analà 1:200 Insertive analà 6:10,000 Receptive oralà 1:10,000 MSW/WSM Receptive analà 1:200 Receptive vaginalà 1:2000 Insertive vaginalà 5:10,000
14 Needle/Trauma Exposure Risk by Encounter Type Needle/syringe sharing à 0.67% per contact Mucous membrane exposure to bloodà 0.1% per exposure Other (eg, human bite)à 0.004%
15 Other Factors Affecting Risk HIV Status / Viral load of source Mucosal integrity Circumcision Sexual Assault
16 Criteria for npep Administer to individuals who present within 72 hours if: Exposure to a source known to have HIV Exposure and in a high risk category Intercourse without a condom Percutaneous exposure to blood Exposure to a mucous membrane/point of entry (eyes, rectum, vagina, OP)
17 The Patient History A thorough history is crucial to determining risk Type of exposure? (activity, fluid, site) Time of exposure? Serologic status of the source? Date of last negative HIV test? Recent h/o viral syndrome? Have they needed npep in the last year?
18 Algorithim for npep
19 Testing Labs at initial visit Rapid HIV in office* HIV 4 th Generation Ag/Ab CBC/CMP/UA Hepatitis Panel RPR, GC/CT Pregnancy testing *If positive, refer to HIV specialist for continued care.
20 Next Steps Patient educationà Avoid secondary transmission (condoms, no fluid donations) Avoid breast feeding Discuss medication SE, adherence, and follow up Prescribe medications F/U schedule for 5-6 weeks
21 HIV Medications by Class NRTI (nukes) Lamivudine** Zidovudine** Emtricitabine* Abacavir (require genetic testing) Tenofovir Disoproxil Fumarate* Tenofovir Alafenemide Didanosine Stavudine NNRTI (non-nukes) Rilpivirne (no PPI s) Etravirine Delavirdine Efavirenz (CNS SE, transmitted resistance common) Nevapirine Fusion Inbibitors Enfuvirtide CCR5 Antagonist Maraviroc (need CCR5 testing) Protease Inhibitors Tipranavir Indinavir Saquinavir Lopinavir Fosamprenavir calcium Ritonavir** Darunavir** Atazanavir sulfate Nelfinavir PK Enhancers Cobicistat (many DDI sà boost levels of most meds) Integrase Inhibitors Raltegravir* Dolutegravir* Viteka *Indicates preferred npep medication **Indicates alternative npep medication
22 Preferred and alternative antiretroviral 28 day regimens for npep Group Preferred/Alternative Medication Adults and adolescents age >13 years, and pregnant women (with CrCl >60 ml/ min) PREFERRED A 3 drug regimen consisting of Tenofivir DF 300mg + Emtricitabine 200mg fixed dose (Truvada) QD With Raltegravir 400 mg BID Or Dolutegravir 50 mg QD Alternative A 3 drug regimen consisting of Tenofivir DF 300mg + Emtricitabine 200mg fixed dose (Truvada) QD With Darunavir 800 mg QD And Ritonavir 100 mg QD
23 Preferred and alternative antiretroviral 28 day regimens for npep Group Preferred/Alternative Medication Adults and adolescents age >13 years with renal dysfunction(with CrCl <59 ml/min) PREFERRED A 3 drug regimen consisting of Zidovudine and Lamivudine with both doses adjusted to degree of renal function With Raltegravir 400 mg BID Or Dolutegravir 50 mg QD Alternative A 3 drug regimen consisting of Zidovudine and Lamivudine with both doses adjusted to degree of renal function With Darunavir 800 mg QD And Ritonavir 100 mg QD
24 ADR/SE Profiles Common SE Headache Nausea Diarrhea Fatigue Dizziness ***Usually resolve within 1 week. ADR Renal Toxicity with TDF/FTCà baseline CMP/UA BMD loss in longterm TDF/FTC use Hepatotoxicityàbaseline LFTs SJS with Darunavir (sulfa allergy) Hyperbilirubinemia with ritonivir
25 Medication Costs q Cost can present barrier to care q Co-pay assistance available on all regimens q PAP also available for uninsured pt
26 Follow up 5 weeks after initiation of npep Review adherence Thorough hx for new exposures Risk reduction counseling (PrEP?) Repeat 4 th Gen HIV visit and at 3m Repeat CBC/CMP/UA
27 Resources for providers UpToDate HIVwebstudy.org à Free CME Your local HIV Specialists: 1. Jason Vercher, PA-C Dallas 2. Amanda Miller, PA-C San Antonio
28 Resources for Patients PAP/Copay assistance: 1. Gileadà TDF/FTC 2. Viivà Dolutegravir, Lamivudine, Zidovudine 3. Jansenà Darunavir/ritonivir q Local Community based testing centers
29 References source=search_result&search=nonoccupation%20post%20exposure %20hiv&selectedTitle=2~150#H
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