Travel Advice: HIV & Post-Exposure Prophylaxis

 

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This information is written specifically for 4th year medical students on electives overseas, regarding HIV risk and post-exposure prophylaxis.

 

Prevention

  • The most effective approach is not to put yourself at risk at all
  • Use good infection control procedures at all times
  • Wear gloves if you are likely to be contaminated with body fluids (take gloves with you)
  • Think about what you will do in the event of an injury before it happens
 

Prevalence

According to the World Health Organisation, the numbers of adults and children estimated to be living with HIV at the end of 2005: 40 million.

 

Epidemiology of HIV world-wide - local seroprevalence

  • Highest in sub Saharan Africa
  • Highest in Central, East, South East and South Africa
  • Up to 20% of the population HIV infected (Botswana 36%)
  • Far East - Thailand (2%) and Cambodia(4%), Caribbean (1-5%).
  • Increasing in India, Eastern Europe and Russia
 

Risk after exposure

  • Risk of acquiring HIV infection following occupational exposure to HIV infected blood is low
  • Average risk for HIV transmission after percutaneous exposure to HIV infected blood in health care settings is approx 1 per 300
  • After mucocutaneous exposure,
  • No risk of transmission where intact skin is exposed to HIV infected blood
 

Calculating HIV seroconversion risk after needlestick/sharps injury

  • Known HIV positive - risk is 1 in 300
  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 3 (i.e. 30%) - risk is 300 x 3 = 1 in 900
  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 10 (i.e. 10%) - risk is 300 x10 = 1 in 3,000
  • HIV serostatus unknown, where prevalence of HIV in local/hospital population is 1 in 100 (i.e. 1%) - risk is 300 x 100 = 1 in 30,000
 

Occupational exposure

Four factors associated with an increased risk of occupationally acquired HIV infection:

  • Deep injury
  • Visible blood on the device which caused the injury
  • Injury with a needle from artery or vein
  • Terminal HIV illness in source patient

Almost all reported cases of HIV seroconversion have occurred after injuries with hollow bore needles.

Body fluids and materials which may pose a risk of HIV transmission

  • Amniotic fluid
  • Cerebrospinal fluid
  • Human breast milk
  • Pericardial fluid
  • Peritoneal fluid
  • Pleural fluid
  • Saliva in association with dentistry
  • Synovial fluid
  • Unfixed human tissues and organs
  • Vaginal secretions
  • Semen
  • Any other fluid if visibly bloodstained
  • Fluid from burns or skin lesions
 

Post-exposure risk assessment [1] Immediate action

  • Wound or non-intact skin to be washed liberally with soap and water without scrubbing
  • Antiseptics should not be used as no evidence of efficacy and effect on local defences unknown
  • Free bleeding encouraged
  • Exposed mucous membranes irrigated with water and remove contact lenses
 

Risk Assessment of Occupational Exposure

Ideally this should not be done by the injured Health care Worker. Assessment of the injury involves:

  • Nature of the injury - was there significant contamination?
  • The risk the patient has HIV (do they have Hep C, Hep B)
  • Known HIV positive
  • Person of unknown HIV serostatus
 

Risk Assessment [2] Circumstances of exposure

Assess if exposure was significant.

  • Percutaneous injury (needles, instruments, bites which break skin)
  • Exposure of broken skin (abrasions, cuts)
  • Exposure of mucous membranes (including the eye and mouth)
 

Risk Assessment [3] The Source Patient

If of unknown HIV serostatus a designated doctor should approach the source patient and ask for informed agreement to HIV testing (this should not be the exposed worker).

Current guidelines for UK Health care workers seconded overseas - HIV post-exposure prophylaxis

Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS, UK Department of Health, February 2004 (currently under revision) 

 

Post-exposure prophylaxis

PEP should ideally be started within 1 hour of the injury. Current EAGA recommendations for UK Health care workers seconded overseas:

  • In areas where no anti-HIV treatment is available for patients: 2 drug combination (Zidovudine 250mg and Lamivudine 150mg bd (Combivir 1 tablet BD) for 28 days). BUT anti-HIV treatment is being rolled out to the local population in many developing countries (parts of Uganda, Malawi, Botswana etc). In these areas anti-HIV treatments are likely to be readily available to staff who have significant occupational injuries (ask your supervisor!)
  • Where drug resistant HIV likely to be present in local population: 3 drug combination recommended for exposures to ‘treatment experienced’ HIV population (Zidovudine 250mg + Lamivudine 150mg BD (Combivir 1 tablet BD) + Nelfinavir 1250mg BD for 28 days).
 

Costs

  • Combivir 1 BD- 7 days = £72.88, 28 days = £291.65 (recommend 7 day pack)
  • Combivir 1 BD + Nelfinavir 1250mg BD- 7 days = £148.48, 28 days =£896.33 (recommend 7 day pack).
 

Questions that you need to answer

  • Will any work during my elective put me at significant risk of contamination with blood borne viruses? If the answer is no, you do not need to consider PEP.
  • What is the prevalence of HIV in the local/hospital population? If high, is the local population being treated with anti-HIV treatments?
  • What is the local process for handling significant exposures/contamination injuries?
  • Are anti-retrovirals locally available within the hospital/health care centre where you are working? If so, which ones, how quickly can they be accessed and cost?
  • Who will manage/advise you in the event of a contamination injury? Contact your local supervisor (although you often don’t get a response!)
  • Consider insurance to cover repatriation in event of significant injury requiring PEP.

Source: Dr Eric Monteiro, Clinical Director, Department of Genitourinary Medicine

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