PEP is a medical response given to prevent the transmission of pathogens after potential exposure. PEP for HIV refers to a set of comprehensive services to prevent HIV infection in exposed individuals. These services include, first aid care, counselling and risk assessment, HIV testing based on informed consent, and depending on risk assessment, the provision of short term (28 days)antiretroviral (ARV) drugs, with follow up and support.

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Dr.Sujnanendra Mishra MD (O&G)

2. What is PEP.
 PEP is a medical response given to prevent the
transmission of pathogens after potential exposure.
 PEP for HIV refers to a set of comprehensive services
to prevent HIV infection in exposed individuals.
 These services include, first aid care, counseling and
risk assessment

3. EXPOSURES
 Occupational exposure to HIV-
“an occupational exposure is defined as a percutaneous,
mucous membrane or non-intact skin exposure to blood or
body fluids that occurs during the course of an individual’s
employment. This applies to health care workers (HCW) and to
non-health workers.”
 Non-occupational exposure to HIV--
Non-occupational exposure is any direct mucosal, percutaneous
or intravenous contact with potentially infectious body fluids
that occurs outside perinatal or occupational situations

4. Components of nPEP
Evaluation
 HIV risk assessment
 HIV and STD testing and treatment
 Prevention and risk-reduction
counseling
 Clinicians able to prescribe
antiretroviral therapy
 Timely access to care and initiation
of PEP

5. Assessing Risk
 Consider the following:
 Risk of HIV acquisition based on type of exposure
 Possibility that the source is HIV-infected
 Circumstances leading to HIV exposure
 Provide risk-reduction and primary prevention
counseling
 nPEP not indicated for negligible or low risk of HIV
infection

6. Risk Behavior
 PEP recommended in situations of:
 Isolated exposure (sexual, needle, trauma)
 Lapse in previous risk-reduction practices
 When patients express interest in behavioral
change
 Repeated high-risk behavior or
presentation for repeat courses of PEP
 Opportunity for intensification of education &
prevention
 Attempt behavioral change

7. *Risk of Acquisition
 The average risk after a percutaneous exposure to HIV-infected blood has
been estimated to be approximately 0.23% (95% confidence interval (CI) =
0.00–0.46%) .
 The average risk after a mucous membrane exposure is estimated to be
approximately 0.09% (CI = 0.006–0.5%) .
 Factors associated with an increased likelihood of transmission include:
° deep (intramuscular) injury
° injury caused by a device that enters a blood vessel
° injury with a hollow-bore needle
° a source patient with a high viral load (VL).
 Episodes of HIV transmission have also been documented after non-intact
skin exposure. It is estimated to be much less than the risk for mucous
membrane exposures.
 The risk for transmission after exposure to HIV-infected fluids or tissues other
than blood has not been quantified either, but it is considered probably
lower than for blood exposure.

8. Situation Needing PEP
PEP recommended, if source HIV PEP NOT recommended
+ or at risk of HIV
*Unprotected receptive & *Kissing, or oral-oral contact & no
insertive vaginal or anal mucosal damage
intercourse *Bites without blood
*Needles/sharps exposure not in contact
*Unprotected receptive penile- with HIV + or at-risk person
oral contact with ejaculation *Mutual masturbation – intact skin
*Oral-vaginal contact with blood *Oral-anal contact
exposure *Receptive penile-oral contact without
*Needle-sharing ejaculation
*Insertive penile-oral contact
*Injury with blood exposure
*Oral-vaginal – no blood exposure
- needle stick, bite, accident

9. Estimated Transmission Risk
Exposure Type if Source HIV- Estimated Risk
infected
Needle-sharing exposure 0.67% (1/150)1
Receptive anal intercourse 0.5% (1/200) to 3% (6/200)2,3
Receptive vaginal intercourse 0.1% (1/1000)3,4
Insertive anal intercourse 0.065% (1/1500)3,4
Insertive vaginal intercourse 0.05% (1/2000)3,4
Oral sex with ejaculation Conflicting data, but felt to be low-
risk. PEP recommended for
performer of oral sex who receives
ejaculate.5,6

10. References for HIV
Transmission Risk
 1) Kaplan EH et al. J Acquir Immune Defic
Syndr 1992;5:1116-1118.
 2) DeGruttola V et al. J Clin Epidemiol
1989;42:849-856.
 3) Varghese B et al. Sex Transm Dis
2002;29:38-43.
 4) European Study Group. BMJ 1992;304:809-
813.
 5) Dillon B et al. 7th CROI, San Francisco, CA
2000; abstract 473.
 6) Page-Shafer K et al. AIDS 2002;16:2350-
2352.

11. Community Needlestick
Injuries
 Consider:
 HIV prevalence in the community or
facility
 Surrounding prevalence of injection drug
use
 DO NOT TEST discarded needles for
HIV
 Consider tetanus vaccination if
puncture wound

12. Bites
 Estimated 250,000 bites annually in the U.S.
 HIV levels in saliva very low
 Documented transmission has involved
blood-tinged saliva 1,2
 Consider PEP when:
 Blood exposure to biter
 Blood exposure to bitten person (e.g. source
has bleeding gums or lesions)
 Blood exposure to both parties
1 Vidmar L et al. Lancet 1996;347:1762-1763.
2 Pretty I et al. Am J Forensic Med Pathol 1999;20:232-239.

13. Considering HIV Status of
Exposure Source
 If HIV-positive source, consider their:
 CD4+ cell count
 Viral load
 Antiretroviral medication history
 Antiretroviral resistance history
 If anonymous or unknown status
source:
 Consider potential risk of HIV infection,
including information on regional
prevalence

14. Contraindications to nPEP
 Prophylaxis for pregnancy attempts
with an HIV-infected male partner
 Prophylaxis for persons planning to
engage in high-risk behavior

15. Risk of HIV transmission
=risk/single exposure
multiplied by the risk of
source being HIV positive.

16. Transmission Risk from the
Exposure
 Determine the specific sexual,
injection drug use, or other behavior
that led person to seek nPEP (see
Estimated Per-Act Risk by Exposure
Route)
 Determine relative risk for HIV
exposure using algorithm for
evaluation and treatment and per-
act risk for acquisition of HIV
AETC National Resource Center, www.aidsetc.org

17. Estimated Per-Act Risk for Acquisition of
HIV by Exposure Route
Exposure Route Risk per 10,000
exposures
Blood transfusion 9,000
Needle-sharing injection drug use 67
Receptive anal intercourse 50
Percutaneous needle stick 30
Receptive penile-vaginal intercourse 10
Insertive anal intercourse 6.5
Insertive penile-vaginal intercourse 10
Receptive oral intercourse 1
Insertive oral intercourse 0.5
March 2008 AETC National Resource Center, www.aidsetc.org

18. RISK communication
Risk Term
1 in 1 to 1 in 10 Very high
1 in 10 to 1 in 100 High
1 in 100 to 1 in 1000 Moderate
1 in 1000 to 1 in 10,000 Low
1 in 10,000 to 1 in 100,000 Very low
1 in 100,000 to 1 in 1000,000 Minimal
1 in 1000,000 to 1 in 1 billion/trillion Negligible
Communicable Disease Control Branch (CDCB) South Australia

19. Risk of HIV acquisition when the source is
KNOWN to be HIV infected
Communicable Disease Control Branch (CDCB) South Australia

20. * Risk of HIV acquisition by exposure to a
non-IDU heterosexual source with HIV
status UNKNOWN
Communicable Disease Control Branch (CDCB) South Australia

21. Assessing Risk of HIV Exposure
Substantial Risk Negligible Risk
of HIV Exposure of HIV Exposure
Exposure of: Exposure of:
 vagina, rectum, eye, mouth or  vagina, rectum, eye, mouth
other mucous membrane, non- or other mucous membrane,
intact skin, or percutaneous intact or nonintact skin, or
contact percutaneous contact
With: With:
 blood, semen, vaginal  urine, nasal secretions, saliva,
secretions, rectal secretions, sweat, or tears if not visibly
breast milk, or any body fluid contaminated with blood
visibly contaminated with blood
When the source is Regardless of the known or
known to be HIV infected suspected HIV status
of the source
AETC National Resource Center, www.aidsetc.org

22. Recommendations for Use of ARVs for nPEP
Substantial Negligible
exposure risk exposure risk
< 72 hours since >72 hours since
exposure exposure
Source patient Source patient of
known to be unknown HIV nPEP not
HIV+ status recommended
nPEP Case-by-case
recommended determination
The Centers for Disease Control and Prevention (CDC) flow diagram for nonoccupational post exposure prophylaxis
(nPEP) decision making, CDC, Morb Mortal Wkly Rep, 2005.

23. PEP should be initiated within hours of
Timing of Initiation exposure – ideally within 2 hours and not later
than 72 hours
after exposure and should not be delayed
while waiting for tests results.
A 28 days course of
Duration of
nPEP is
treatment
recommended
Follow-Up

24. Two ARV drug regimens
Two-drug ARV regimens
Preferred ZDV + 3TC or FTC (a)
Alternatives TDF + FTC or 3TC(b)
or
d4T + 3TC
a The combination ZDV + 3TC is available as a fixed-dose combination
(FDC) (Combivir), one tablet twice daily (BID).
b The combination TDF + FTC is available as an FDC (Truvada), one
tablet once daily (OD).
March 2008 AETC National Resource Center, www.aidsetc.org

25. Three-drug ARV regimens
Recommended for exposures that pose an increased risk of transmission
or that involve a source in whom antiretroviral drug resistance is likely.
Preferred ZDV + 3TC or FTC (a)
Alternatives TDF + FTC or 3TC (b)
or
d4T + 3TC
a The combination of ZDV + 3TC is available as an FDC (Combivir), one tablet BID.
b The combination of TDF + FTC is available as an FDC (Truvada), one tablet OD.

26. ARV dosages (Adults)
• ZDV: 300 mg per os (PO), BID with food
• 3TC: 150 mg PO, BID or 300 mg PO, OD
• FTC: 200 mg, PO, OD
• TDF: 300 mg, PO, OD
• d4T: 30 mg PO, BID
• LPV/r: 400 mg/100 mg PO, BID with food
• SQV/r: 1000 mg/100 mg PO, BID
• ATV/r: 300 mg/100 mg PO, OD
• FPV/r: 700 mg/100 mg PO, BID
Children who need PEP, dosages should
be adjusted by body weight

27. Follow-Up
People who have been potentially exposed to HIV, whether
occupationally or non-occupationally, should receive follow-
up treatment.
• Counseling, post-exposure testing and medical evaluation
should be provided to all exposed
people, regardless of whether they receive PEP or not.
• If taking ARVs patients should be followed up for
adherence and possible side-effects of ARVs
(e.g. nausea or diarrhoea) should be managed
symptomatically without changing the regimen.

28. Final Words
Advice on safe practices
• Safe sex.
• Safe needle use.
• Safe Work practices.
• Safe infant feeding.
• Safe Blood/Organ donation.
A person with a possible exposure to HIV should be advised not
to donate blood, skin, or organs for the six month following the
exposure.