HIV Non-Occupational Post-Exposure Prophylaxis (PEP)



Canberra Hospital and Health ServicesClinical Guideline HIV Non-Occupational Post-Exposure Prophylaxis (PEP)Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc496607415 \h 1Guideline Statement PAGEREF _Toc496607416 \h 2Scope PAGEREF _Toc496607417 \h 2Section 1 – HIV Non-Occupational Post-Exposure Prophylaxis (PEP) PAGEREF _Toc496607418 \h 2Implementation PAGEREF _Toc496607419 \h 4Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc496607420 \h 4References PAGEREF _Toc496607421 \h 5Definition of Terms PAGEREF _Toc496607422 \h 5Search Terms PAGEREF _Toc496607423 \h 5Attachments PAGEREF _Toc496607424 \h 6Attachment A – Indications for HIV PEP PAGEREF _Toc496607425 \h 7Attachment B – PEP Medications and cautions PAGEREF _Toc496607426 \h 8Guideline StatementTo outline the procedure for patients presenting to the Canberra Hospital Health Services (CHHS) Emergency Department for HIV Post Exposure Prophylaxis (PEP) following possible HIV exposure.Back to Table of ContentsScopeThis document applies to adult, adolescent or paediatric patients that present for HIV Post Exposure Prophylaxis (PEP) at CHHS.This document applies to the following CHHS staff working within their scope of practice:Medical OfficersRegistered Nurses and MidwivesStudent Nurses and Midwives working under supervision Back to Table of ContentsSection 1 – HIV Non-Occupational Post-Exposure Prophylaxis (PEP)Triage:If patient presents within 72 hours of exposure, access to HIV PEP is time critical. HIV PEP should be commenced as soon as possible after an actual or potential exposure to HIV, and at the latest within 72 hours. Obtain history:History of exposure:Time and date of exposure; calculate time since exposureNature of exposurereceptive anal intercourse - with or without ejaculationinsertive anal intercourse - uncircumcised or circumcisedreceptive or insertive vaginal intercoursereceptive or insertive oral intercourseneedlestick injury or other sharps exposureshared needles and other injecting equipment mucous membrane and non-intact skin exposureHIV status of source individual if the source is contactable: Note: PEP commencement should not be delayed even in circumstances when the source cannot be contacted immediatelyIf source is known to be HIV positive, check:current HIV medication and most recent HIV viral load. Undetectable viral load = <50 copies/ml. prior anti-HIV medications and resistance assaysIf source is known to be taking pre-exposure prophylaxis (PrEP), check adherencePEP is generally not required but should be considered if there are concerns about source non-adherence to PrEP. If source chooses not to disclose their HIV status or have an HIV testassume for the purposes of PEP prescription that they are HIV positive.If the source cannot be contacted, try to establish if they have any of the following risks:men who have sex with other meninjecting drug usecoming from country of higher HIV prevalence (in particular, sub-Saharan Africa or South East Asia)Assess HIV status and medical history of exposed person:Current illnesses, medications, allergiesHepatitis B vaccination or infection statusHepatitis C infection statusPregnancy or pregnancy risk – all women presenting for PEP should be assessed with pregnancy test and offered emergency contraception if appropriatePrior HIV testingPhone the Infectious Diseases (ID) Physician on-call with the above history in order to confirm that HIV PEP is appropriate for the exposure (HIV PEP indications are available via link in Attachment A) and to clarify potential drug-drug interactions (see Attachment B).Decisions about whether or not to commence HIV PEP can be complex. Staff should clearly present patient concerns to the ID physician on call so that the decision to prescribe or not to prescribe PEP can be more easily communicated to the patient.In the ED, all patients are provided with a 3 drug starter pack (5 day initial supply) if PEP is indicated. This will be reviewed during follow-up at Canberra Sexual Health Centre when PEP may be simplified to 2 drugs.Note: If the patient is a child(Less than 16 years old), provide ID physician with their age and weight. If PEP is indicated, medications and dosages may require rm patient/caregiver that PEP is a 28 day course of medication, which reduces but does not remove the risk of HIV seroconversion. Baseline HIV testing is required with follow-up HIV testing at 6 weeks and 3 months. Alert:Until final follow-up tests are confirmed as negative patient must avoid risks of transmission of HIV through sexual contact or sharing of blood or other body fluids.Obtain consent with appropriate pre-test discussion and collect baseline serology: HIV, HBV, HCV and syphilis, plus electrolytes, urea, creatinine (EUC), liver function tests (LFT), phosphate and pregnancy test if appropriate.Results will be provided at Canberra Sexual Health Centre when attending PEP follow-up. Provide PEP starter pack and go through PEP medication consumer handout. Inform patient/caregiver that they will be required to attend CSHC within 5 days to receive follow-up and the remainder of their medication.Other medical care:Consider need for Hepatitis B prophylaxis as per Australian Immunisation HandbookIf contaminated wounds or abrasions, assess need for tetanus vaccination as per Australian Immunisation Handbook. Back to Table of Contents Implementation The guideline will be placed on the CHHS Policy Register. Individual notification of the change of medication will be made to senior managers in Emergency Departments, Pharmacy and Infectious Diseases departments at Canberra Hospital and Calvary Hospital. These managers will inform their staff through staff meetings.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationLegislationHealth Records (Privacy and Access) Act 1997 (ACT)Medicines, Poisons and Therapeutic Goods Act 2008 (ACT)Policies and proceduresHealthcare Associated Infections ProcedurePatient Identification and Pathology Specimen Labelling Policy Patient Identification and Procedure Matching Policy and Procedure Time to Treatment in the Emergency Department PolicyNursing and Midwifery Continuing Competence PolicyConsent to Treatment PolicyConsumer Handouts HIV Post-exposure Prophylaxis (PEP) Medication Consumer HandoutBack to Table of ContentsReferencesASHM, National Guidelines for Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV (Second edition), August 2016 Post-exposure Prophylaxis for HIV: Australian national Guidelines (accessed 13 October 2017).Department of Health and Aging, The Australian Immunisation Handbook. 10th ed, 2013.Back to Table of ContentsDefinition of TermsED Emergency DepartmentHBV Hepatitis B VirusHCVHepatitis C VirusHIVHuman Immunodeficiency VirusPEPPost Exposure ProphylaxisHSVHerpes Simplex VirusIDUInjecting Drug UseSTISexually Transmissible InfectionBack to Table of ContentsSearch Terms Non occupational exposure, HIV, PEP, sexual health, ED, emergency, post, exposure, prophylaxisBack to Table of ContentsAttachmentsAttachment A – Indications for HIV PEPAttachment B – PEP Medications and cautionsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.(to be completed by the HCID Policy Team)Date AmendedSection AmendedApproved BySection 1ED/CHHSPC ChairAttachment A – Indications for HIV PEPSee page 10 of ASHM, National Guidelines for Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV (Second edition), August 2016 For PEP recommendations after: exposure to known HIV status sourceexposure to source with unknown HIV statusNote: In the ACT, all patients are provided with a 3 drug starter pack if PEP is indicated. This will be reviewed at Canberra Sexual Health Centre when PEP may be simplified to 2 drugs.Attachment B – PEP Medications and cautionsTenofovir and EmtricitabineGenerally well toleratedMild to moderate gastrointestinal side effects of nausea, vomiting, diarrhoea; tiredness, headacheUse with caution or avoid if renal impairment eGFR <60ml/minRequires dose reduction if eGFR < 50 ml/minDolutegravirGenerally well toleratedDrugs that are contraindicatedDofetilide (not available in Australia)Drugs that should be used with caution Phenytoin, phenobarbital, rifampicin, St John’s Wort, carbamazepine - increase dolutegravir dose to 50mg BD or stop St. John’s Wort. Antacids containing polyvalent cations e.g. Mg or Al – use at least 2 hours before or 6 hours after the dolutegravir dose. Products containing calcium or iron – use at least 2 hours before or 6 hours after the dolutegravir dose OR dose concomitantly with food. Metformin – increase monitoring of glycaemic control, adjustment in metformin dose may be required.A full drug interaction check can be made on the Liverpool HIV Drug Interactions site ................
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