Tuesday, December 28, 2010

prevent AIDS/ HIV through PEP.

  Preventing AIDS by PEP

   Good evening every one. Maximum of you might be knowing my intention behind writing this note at a very short notice. I was just shocked to see that we are not aware what to do in case of accidental needle prick. I felt sorry for the concerned dr that we lost lots of time in exchanging mails.


I will try to give all details at my level best so that in future this type of situation could not arise.

 PEP  or[ post exposure prophylaxis] is term used for prophylaxis to prevent hospital staff or any one else after any kind of exposure from HIV infected source.

 the post exposure prophylaxis to HIV is the only way to reduce risk of development of HIV infection after any exposure.

It is a short term antiretroviral treatment that reduces the risk of HIV after exposure.

It has to be given in case of any occupational hazard like needle pricks and non occupational like sexual violence.
But in no situation it should be used as morning after pill and precautions should be taken to prevent the risks and emphasis on the PEP should be judicial.

IN CONTROLLED study it has been found to prevent HIV . but incidence of failure has also been recorded.


MODE OF TRANSMISSION
Transmission can spread from body fluids i.e blood and CSF and through mucosa. It can spread through mucosa and percutaneous but incidence is low.
Let me tell you here that with needle prick which is generally percutaneus the chances of infection found is 0.3 percent from HIV, 30 percent Hepatitis B/ HBV and 13 percent from hepatitis C/HCV with single exposure.

RISK ASSESSMENT FACTORS

Time lag between exposure and consultation.
 Please remember this is the most significant part of prevention. In every hospital at emergency dept single dose of ART is generally available. It should be consumed with in hour of exposure and send the person to ART centre for further evaluation.
 I am discussing rest of these for awareness purpose. Otherwise team at ART centre is better equipped to handle and decide if PEP should be started or not.
1.     Nature of exposure if skin cut mucosal or percutaneous.
2.     Type of contact
3.     Severity of the injury
And protective measures after exposure which includes PEP.

These will be considered as High risk factors

Injury with instrument visibly contaminated with infected blood.
Pricking of needle giving direct entry in vein or artery.
Deep injury.
Exposure to AIDS patient having high virus load. [ stage of patient can be ascertained by judging if he is full blown AIDS or not.] or heavy CD4 count.
All these factors will help in  deciding if further treatment is required or not.

Counselling and psychological support is very important.

All potential risk of infection may get symptoms like fever skin rash sore throat swollen glands . or some times not specific symptoms like fever and headache only.
Some times there is delay in presenting symptoms too.


Post exposure…

Pathologically there is time lag in between HIV exposure .it goes like  viral seeding,replication and infection. Antiretroviral therapy  help in stopping this chain.
Success of PEP is highly dependable on its early initiation.
PEP  has shown ineffective results in animal study after 72 hours.

Neverthe less there is no full proof success.

Draw backs
 I want to discuss it here  as I have written it should not be used by habitual risk takers as a morning after pill. The therapy has severe side effects and more than 30 percent of individuals left the therapy in between because of intolerance. So precaution is the only best way to prevent.
Most of the sideeffects are malaise, diarrhoea, nausea impaired vital functions.

The PEP therapy generally in use

Though zidovudine has been the most effective but combination therapy is best provided.
PEP  success is in time only…the earlier we start the better risk we are neutralising. In many countries practice is of two drug therapy and in some three drug. According to new guidelines provided by WHO , it is three drug for high risk exposure and two for low risk.
So in emergency we need to keep just zidovudine and 3TC for first immediate dose and redirect the case for better handling at ART centre.

let me sum up again.


 Try to find out nature and degree of exposure.  HIV status of the  source

And to  start PEP if any factor showing risk of infection

Basic first dose AZT and 3TC can be offered  with in hour after washing the site with soap water.

At ART centre after counselling or finding the source of infection nil we may stop  further PEP therapy.
Else we shift to three drug regime which is more suitable and have to continue for atleast 4 weeks.

Now the course of action will be

Test for HIV anti body at 0, 3, 6  and 12 months.
CBD, R/LFT, (aamylase,CPK, sugar at 0,2,4 weeks and  at 3, 6 months) is required to monitor drug tolerance as I earlier stated.
Warning against any seroconeversion illness.

Here if after all this HIV positive result is shown it has to be referred  for HIV management.

If  PEP  was not indicated and stopped after counselling and emergency dose. Here the course of action will be

HIV antibody at 0, 3 , 6 month.
Warn against any seroconversion illness any time in between.
If nothing happens..case can be closed.

Follow up HIV antibody test shall be performed at 6 month. A test earlier than this can be done at 3rd month too. And an additional 12th month testing is considered for high risk PEP group to check possibility of late seroconversion. HIV antibody testing and HIV RNA testing
Can be done for suspected seroconversion cases.

Lastly don’t forget to rule out HBV and HCV. Vaccines are readily available to prevent all this.


                           WISH U ALL SAFE PRACTICE AND 2011

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