Prevention of transmission of HIV and other bloodborne viruses in healthcare and post exposure prophylaxis John Ferguson, UPNG 2012
Outline Epidemiology Making the diagnosis / contact tracing Antiretroviral therapy : who to treat, what drugs? Vertical transmission prevention Monitoring and follow-up Public health action PNG Prevention of transmission in healthcare and post exposure prophylaxis
Standard Infection Control Precautions primary aim is to prevent bloodborne virus transmission Hand hygiene before and after patient contact Use of gloves and other personal protective equipment to prevent direct blood or body fluid exposure to skin or mucous membranes eg. The eye Safe handling and disposal of sharp instruments Safe containment of blood and other body fluid spills Proper handling of contaminated waste and soiled linen Disinfection (and sterilisation) of contaminated reused equipment
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 exposure 2. The source -?Known +ve HIV? stage - If status unknown,? epi risk
Management: First Steps Clean wound (soap and water). No caustic agents Flush mucous membranes with saline Vaginal/rectal douching not recommended Assess tetanus, hepatitis B vaccination status Organise pre-test counselling Risk assessment: risk of exposure multiplied by the risk that the source is infective
Type of Exposure Receptive anal intercourse Receptive vaginal intercourse Insertive vaginal or anal Needle injury Using contaminated needles Mucous membrane HIV 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%) Current HIV seroprevalence in PNG (0.92%) Hospitalised medical patient much higher up to 20%
Other Risk Factors: 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 exposure PNG risk equation for hospital needlestick - risk of seropositivity 1 in 5 X risk of exposure (eg. 3 in 1,000 for needlestick) = 3 per 5,000
HIV Exposure management: What needs to be discussed Discuss the issues for the individual, and document this in the notes Carefully explain the risks Risk reduction in transmission by giving post-esposure prophylaxis with ARV estimated to be 66% Protection for others still needed (condom, needle sharing, breast feeding, blood donation, work practices) Side effects of drugs (don t confuse with seroconversion) 4 weeks therapy required (can be difficult) It is the choice of the patient and can stop anytime Need for follow-up counselling and support!!!!!
The drugs: which one 2 drugs most commonly: Combivir (AZT/3TC) Truvada (TDF/FTC) Given for 28 days; initiate rx within 12 hrs best (max 72 hrs) Factor drug history of source/ risk of resistance Don t forget other STDs, Hepatitis risks, tetanus Follow-up testing for bloodborne viruses
Follow up Post-test counselling 3 months follow up for HIV if no PEP 6 months follow up for HIV if PEP given 6 months follow up for hepatitis B and C Advice re avoiding future exposures Contact tracing issues
Prevention of bloodborne virus exposure in hospital Mindfulness about the task at hand- avoid distraction Setup separate trolley, mobile sharps bin Disposal always dispose safely of sharps created by you! No re-sheathing of needles Always use gloves if blood/body fluid exposure is possible = Standard precautions Use protective eye-wear during collection of blood/other procedures Alcohol hand rub to disinfect hands before and after procedure
Blood/body substance exposure Know your status! HIV- are you seropositive? Do you need treatment? Hepatitis B- are you a carrier, are you immune? Do you need to be vaccinated? Hepatitis C- are you seropositive? Protect yourself Use correct procedures and personal protective equipment Use hand hygiene with alcohol hand rub