Module 4:

Post Exposure Prophylaxis

Objectives
At the end of the module, the participants should be
able to:
• Define and learn the importance of post exposure
prophylaxis
• Identify the risk of occupational transmission of
HIV and other blood borne STIs
• Master the PEP algorithm and treatment protocol
in HIV and other blood borne STIs post exposure
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 Definition and Importance
● PEP is a series of immediate counseling, testing and giving
of treatment
● Occupational transmission of HIV and other blood borne-
STI’s is reduced among healthcare personnel
● 79% reduction in HIV exposure
● 75% reduction in Hepatits B exposure
● Post Exposure Management for Hepatitis C will help in the
early detection of infection
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 Risk of occupational transmission of HBV
HIV Hepatitis B Hepatitis C
• 0.3 % after • depends on degree of • 1.8% ( 0-7 %) after
percutaneous blood contact and HBeAg percutaneous exposure
exposure status of source person • needle prick injury
• 0.09 % after from hollow- bore
• 27%- 62% if source is
mucocutaneous needles
both positive in HBsAG,
exposure
HBeAg • no transmission
• virus survive for
• 1%- 37% if with negative reported in intact or
only few hours in
HBeAg non intact skin
dried blood
exposure
• virus can survive 7 days or
more in dried blood • virus can survive from
16 hours to 4 days in
dried state
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 Who are to be given PEP?
Healthcare personnel who:
• Has direct contact with patients and exposures to
mucosal splashes and sharp injuries
• Handles sharps or bodily fluid-stained materials
• If personnel has dermatitis, abrasions, and open
wound

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General Algorithm for HCP
Report incident to HIV AIDS
Core Team (HACT) or Infection
Control Committee (ICC)
Include the ff details:
• Employee identification
• Date, time, and place of
ACCIDENTAL exposure
EXPOSURE
• Details of exposure
including amount and type
fluid or material and
severity of exposure
• Circumstances surrounding
the exposures

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 General Approaches to Management
1. Initial Treatment: 2. Identification of 3. Evaluation of the 4. Evaluation of
FIRST AID exposure and risk source person Exposed HCP
assessment • Note the medical NOTE the
• Bleeding of
History, risk behavior, following:
wound/ pricks • Characterize the testing for Hep B/C, HIV • Hep B/C, HIV
• Washing exposure to blood • KNOWN HIV/ Hep B (+), status
• Flushing out with and other body START PEP on the • if (+) or with
water fluids exposed person HIV symptoms
• Report to ICC (percutaneous, • KNOWN Hep C (+), at initial visit,
immediately mucosal, direct START PEM on the NO PEP, refer
(within 6 hours skin) exposed person to treatment
• unknown source status, hubs
post exposure)
ff treatment protocol for
UNKNOWN SOURCE
STATUS
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 Treatment : PEP
HIV Hepatitis B Hepatitis C
• PEP kit • Hepatitis B vaccine • Pegylated
• Basic regimen: AZT • 10 mcg/ 0,5 ml interferon and
and 3TC x 3days monodies vial (pediatric) Ribavirin ( 40-
80 % response
• Expanded regimen: • 20 mcg/ ml monodies
rate )
AZT, 3TC and Boosted vial ( IM adult > 10 yo )
protease inhibitors (if • Interferon
• 3 doses at 0, 1, 6
the source person has mono therapy
months
history of ART
resistance)
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 PEP Guidelines
• Patient consent form for TESTING and MEDICATION
• Pregnancy test kit ( OPTIONAL )
• Patient and doctor guidelines Consultation with HACT if:
• Waiver for refusal of baseline testing and PEP • PEP initiation > 72 hours
initiation post exposure
• Immediate evaluation of exposed HCP
• UNKNOWN HIV status of
the source person
• Immediate initiation of PEP
• Pregnant/ Breastfeeding
• NO PEP > 72 hours after exposure exposed HCP
• for UNKNOWN source status but with probable risk, • Source person is a
START 2 drug ARV regimen known ART resistant
• Administration and completion of medicines for 4 • Drug toxicity issue
weeks

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Treatment Protocol: HIV PEP
1. Pre-test counseling 2. Testing (baseline and
• HIV antibody testing discussion follow up)
• assessment of mental and
Baseline testing ( time of exposure)
emotional status of the patient
• HIV status (exposed HCP)
• informed consent for baseline
• Basic tests: FBS, CBC, BUN,
testing
Creatinine, ALT, AST, Urinalysis
• prevention of transmission
Follow up testing
• confidentiality
• Repeat testing ( 3rd and 6th
month)
• Repeat basic tests ( 2 weeks post
PEP commencement )
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Treatment Protocol: HIV PEP
3. Post testing counseling
• exposed HCP who underwent baseline testing
• emotional support
• referral to appropriate organizations/ institution
• issue to discuss prior to PEP initiation ( risk, follow-up,
window period )

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 Evaluation of Exposure and Risk Assessment
Type of Exposure More Severe Less Severe
Large (<18 gauge needle), deep injury, Solid needle, superficial injury, no
Percutaneous visible blood on needle device visible blood on needle/device

Mucocutaneous Major splash Few drops

High Risk Moderate Risk Low Risk

Probability of contact with Probability of contact Low risk of contact with
blood, body fluids, large with blood, body fluids blood, mucosal splash
Procedure volume mucosal splash, unlikely unlikely
uncontrolled bleeding
Blood or body fluids CSF, pleural, pericardial, Urine stool, nasal,
Materials peritoneal, amniotic, secretions, sputum, tears,
vaginal and semen vomitus (if not bloody)

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 Status of Source
HIV Positive HIV Unknown HIV Negative
Low Titer High Titer
Percutaneous and large NO PEP NEEDED
• Asymptomatic & • Advanced AIDS, volume mucosal exposure:
high CD4 count, low • Continue with Hep B
Primary HIV, high VL
VL (<1,500 copies)
NO PEP NEEDED and Hep C screening
or low CD4 count
Consider PEP if high risk
factors present
Percutaneous and Any mucosal and
large volume percutaneous Small volume
mucosal exposure: exposure: START mucocutaneous exposure:
START PEP PEP NO PEP NEEDED
Small volume Continue with Hep B Continue with Hepa B and
mucosal exposure: and C screening Hepa C screening
PEP NOT
RECOMMENDED
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 Care Pathway for people exposed to HIV

Counseling
Assessment Prescription Follow-up
and Support
• Clinical Assessment • Risk of HIV • PEP should be • HIV test at 3 months
of exposure
• Risks and benefits initiated ASAP after exposure
• Eligibility of PEP •28-day prescription • Link to HIV
Assessment of PEP
• Side Effects of recommended treatment if possible
• HIV testing of ARV
exposed people and • Enhance adherence • Provision of
counseling • Drug information prevention
source
• Specific support for • Assessment of intervention as
• Provision of first appropriate
legal cases underlying
aid
comorbidities and
possible drug-drug
interaction
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Treatment Protocol: Hep B
1. All HCP should have vaccination prior to
employment
2. Anti-HBs titer should be taken 2-3 months
after completion of vaccine series
3. Hepatitis B status of source person should be
taken

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 Hepatitis B PEP
Post exposure management for Hep B (including PEP)
Treatment
Vaccination/ Antibody
response of workers Source unknown or not
HBsAG (+) source HBsAg (-) source
available for testing
HBIG (0.06ml/kg IM route) x
Unvaccinated Vaccinate Vaccinate
1 plus vaccine
Vaccinated: Responder
(adequate anti-hbs >10 No PEP No PEP No PEP
mIU/ml
HBIG (0.06ml/kg IM route) x
1 plus revaccinate OR HBIG x If known high risk, treat
Vaccianted: Non- responder No PEP
2 ( time of exposure and 1 as HBsAG (+)
month post exposure

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Treatment protocol Hep C
1. Testing
Baseline testing:
• Anti-HCV status (source and exposed person)
• Time of exposure
Follow up testing: HCV RNA testing
• Anti-HCV status (exposed HCP) (rapid diagnosis)
• ALT level (exposed HCP) • 4-6 weeks
• At 4th – 6th month after exposure
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Sample
Forms

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Review Questions:
1. What is PEP?
2. When is a healthcare personnel (HCP) candidate
for PEP?
3. What are the recommended serological tests
after an exposure?

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