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Dip GUM > PEPSE / PrEP > Flashcards

PEPSE / PrEP Flashcards

1
Q

factors influencing efficacy of PEPSE

A 
timing of initiation 
transmission of a resistant virus
variable genital tract penetration of the drug
poor / non-compliance
further high risk sexual exposures
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2
Q

Factors increasing the risk of HIV transmission

A

High viral load of the source
breaches in the mucosal barrier - ulcers / trauma
menstruation / other bleeding (theoretical)
other STI in a HIV +ve pt not on ARVs
Ejaculation
Non-cicumcision
discordant VL in the genital tract

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3
Q

HIV prevalence sex workers

  • in UK / Western Europe
  • Central Europe
  • Eastern Europe
  • Male CSWs
A

HIV prevalence sex workers

  • in UK / Western Europe = <1%
  • Central Europe = 1-2%
  • Eastern Europe = 2.5 - 8%
  • Male CSWs = 14%
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4
Q

Which medications are usually used for PEPSE

A

Tenofovir- DF and emtricitabine (Truvada)
AND
raltegravir 400mg BD

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5
Q

Timeframe from sexual exposure to start PEPSE

A

72 hours

ideally within 24 hours

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6
Q

At what transmission risk is PEPSE indicated

A

> 1 : 1000 - recommend
1 : 1000 - 1 : 10,000 - consider
<1 : 10,000 - not required

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7
Q

Is PEPSE required if the source is HIV +ve on ART with an undetectable VL

A

No

If on ART with a sustained undetectable VL for a minimum of 6 months

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8
Q

HIV risk of transmission per exposure for:
receptive anal intercourse - average
- with ejaculation
- without ejaculation

A

HIV risk of transmission per exposure for:
receptive anal intercourse - average = 1 : 90
- with ejaculation = 1 :65
- without ejaculation = 1 : 170

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9
Q

HIV risk of transmission per exposure for:
insertive anal intercourse - average
- not circumcised
- circumcised

A

HIV risk of transmission per exposure for:
insertive anal intercourse - average = 1:666
- not circumcised = 1: 161
- circumcised = 1:909

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10
Q

HIV risk of transmission per exposure for:

  • insertive vaginal intercourse
  • receptive vaginal intercourse
A

HIV risk of transmission per exposure for:

  • insertive vaginal intercourse = 1 : 1219
  • receptive vaginal intercourse = 1 : 1000
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11
Q 
If the source is known HIV +ve not on ART 
what is the risk of transmission for:
- human bite
- semen splash to eye
- oral sex - receptive or insertive
- blood transfusion 
- needlestick injury 
- sharing injecting equipment
A 
If the source is known HIV +ve not on ART 
what is the risk of transmission for:
- human bite = <1 : 10, 000
- semen splash to eye = <1 : 10, 000
- oral sex - receptive or insertive = <1 : 10, 000
- blood transfusion = 1 : 1 = 100%
- needlestick injury - 1 : 333
- sharing injecting equipment 1 : 149
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12
Q

If the HIV transmission risk falls in the consider PEPSE range then what factors may suggest it should be given

A

Source patient has a diagnosed STI
breaches in the mucosal barrier (ulcers, trauma)
primary HIV infection in the source patient
victim of sexual assault / traumatic intercourse
> 1 high risk sexual contact within 72 hours
menstruation or other bleeding

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13
Q

Calculation for estimating the risk of HIV transmission

A

Risk of HIV transmission = risk source is HIV +ve X risk per exposure

e. g. Manchester MSM = x receptive anal intercourse with ejaculation
8. 6. / 100 X 1/65 = 1 / 757

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14
Q

Management of a patient requiring PEPSE in A+E

A

sexual history
medical history,
medication and OTC, Allergies
alcohol , smoking

4th generation POCT
Send 4th generation venous sample for HIV, STS, HBV and HCV
U+Es, LFTs
Urine ACR
UPT if required
1st dose of HBV vaccination
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15
Q

Management of a patient requiring PEPSE in a GUM clinic

A

sexual history
medical history,
medication and OTC, Allergies
alcohol , smoking

4th generation POCT
Send 4th generation venous sample for HIV, STS, HBV and HCV
STI screen
U+Es, LFTs
Urine dip for proteinuria - if present send urine ACR
UPT if required
Consider emergency contraception 
1st dose of HBV vaccination
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16
Q

What should we advise a patient when starting PEPSE

A

rationale for PEPSE
drugs are not licensed for PEPSE but commonly used
full course = 28 days
continue PEPSE if baseline bloods comeback +ve
Usually no or mild SE - GI upset
Baseline liver and renal function - drugs occasionally affect these
Safe sex / risk reduction advice / avoid further high risk sexual exposures
PEPSE not 100% effective
FU HIV test 12/52

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17
Q

What follow should be offered for patients started on PEPSE

A

review bloods at 48 hours
2 / 52 repeat STI screening, check adherence, SE, 2nd HBV vaccination
12 / 52 repeat HIV and STS bloods

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18
Q

Management of a patient who attends GUM clinic after receiving a 5/7 starter pack of PEPSE from A+E

A 
baseline bloods if not done or not available
- HIV, STS, HBV, HCV, U+E, LFTs
urine ACR 
Ask re timing of PEPSE and adherence 
Any SE
Continue PEPSE for full 28 days
STI screening
1st HBV vaccination  if not done
offer HAV vaccination + / - HPV
FU in 2/52 and 3/12
health promotion / safer sex / risk reduction
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19
Q

Management of an <16yo requiring PEPSE

A

Assess per adult guidelines if >13 yo and >35kg
Commence adult dose
refer to HIV transition team for follow up with paeds HIV team

if <13yo or <35kg - refer to CHIVA guidelines and refer to the paeds HIV team
medication type and dose is age and weight dependant

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20
Q

Management of a pregnant patient requiring PEPSE

A

Pregnancy does not alter the decision to start PEPSE

calculate risk and offer if >1:1,000

POCT,
4th gen venous sample,
sexual heath screening - incl STS, HBV, HCV

Serum U+E
LFTs
urine dip for protein

explain PEPSE medications are unlicensed in pregnancy

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21
Q

recommendations for missed doses of PEPSE

A

Always reinforce the importance of adherence

<24 hours since last dose - take missed dose immediately and next at usual time

24 - 48 hours since last dose - continue PEPSE

> 48 hours since last dose - stop PEPSE

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22
Q

Management of a further high risk sexual exposure during the last 2 days of a PEPSE course

A

continue PEPSE for 48 hours after last high risk exposure

Discuss PrEP

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23
Q

when should patients on PEPSE be advised to return for an urgent review?

A

rash
flu-like illness
(to exclude HIV sera-conversion)

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24
Q

Management of a patient on PEPSE who has a positive baseline HIV test

A

continue PEPSE until reviewed by a HIV specialist

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25
Q

Alternative to raltegravir in PEPSE for patients who cannot take it

A

dolutegravir

integrase inhibitor

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26
Q

Why is abacavir not reccomended for PEPSE

A

8% of patients will have a hypersensitivity reaction
Requires HLA-B * 570 screening test before initiation

Abacavir = NRTI

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27
Q

Rationale behind PEPSE

A

window of opportunity to avert HIV infection
inhibiting viral replication following exposure

HIV crosses a mucosal barrier
takes 48–72 h before HIV detected in regional lymph nodes
take 5 days before HIV detected in blood

Animal models = Initiation of ART reduces dissemination + replication of virus in all tissues if initiated early after inoculation

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28
Q

What should be considered regarding PEPSE if a person has had multiple exposures within 72 hours

A

cumulative risk should be considered

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29
Q

HIV prevention strategies

A 
Condom use - M or F
Safer sex
PEPSE
PrEP
ARVs - U=U and prevention of vertical transmission 
HIV testing
STI testing and treatment
Blood screening 
Not sharing needles
(Male circumcision)
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30
Q

Advice regarding PEPSE if source HIV status is unknown

A

Attempt to contact partner and arrange testing of them - then stop PEPSE if they test negative

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31
Q

Is PEPSE recommended if the source HIV status is unknown but they are from a risk-group or country of high HIV prevalence (> 1%)

A 
Routinely recommend for:
  - Receptive anal sex
Consider for : 
  - Insertive anal sex 
  - Receptive vaginal sex 
  - Insertive vaginal sex 
  - Sharing of injecting equipment
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32
Q

In what circumstance would PEPSE be recommend when the source is known HIV positive with an undetectable VL
( < 200)

A

Source does not have a confirmed VL < 200 for >6 months

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33
Q

Regarding a patient started on PEPSE - what information should be obtained from a HIV positive source?

A

plasma HIV viral load
resistance profile
treatment history of the source

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34
Q

What is the risk of HIV transmission from a semen splash to the eye

A

no documented HIV transmissions via this route

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35
Q

Is PEPSE recommended ollowing fellatio with ejaculation

A

PEPSE is ‘not-recommended’
The risk is <1/10,000

Case reports of oral transmission exist

Offer PEPSE in extreme circumstances
e.g. primary HIV infection and oropharyngeal trauma/ulceration

36
Q

Is PEP recommended for a needlestick injury from a needle found in the community
e.g. on the street

A

No

  • not possible to determine if the needle has been used and for what purpose
  • HIV status of the source unknown
  • interval between needle use and the exposure
37
Q

what is the timeframe for HIV becoming non-viable

e.g. on an abandoned needle in the community

A

HIV becomes non-viable within a couple of hours -
once the blood has dried

viable HIV cannot be detected after 24 h

38
Q

Items to discuss with individual initiating PEPSE:

A
  1. rationale for PEPSE
  2. lack of conclusive data for efficacy of PEPSE
  3. potential risks and side effects
  4. arrangement for early follow-up with an HIV/GU medicine clinician
  5. Pre-test discussion and HIV test (4th generation laboratory test).
  6. continue PEPSE for 28 days if the baseline result is negative.
  7. The need to have a follow-up HIV test 8–12 weeks post-exposure.
  8. safer sex for the following two months
  9. Emergency contraception
  10. Coping strategies, assessment of vulnerabilities, social support.
  11. offer ongoing risk reduction work / referral to
    psychology
39
Q

Is PEP recommended after human bites

A

No
The risk of transmission is unknown
Likely to be extremely small

Can consider in extreme circumstances - blood in the oropharynx from trauma or deep wounds were caused by the bite

40
Q

Is PEPSE recommended after sexual assault

A

transmission of HIV is likely to be increased as a result of any trauma following aggravated sexual intercourse (anal or vaginal)

recommend PEPSE
particularly if the assailant from high prevalence group

41
Q

Duration of PEPSE

A

28 days

42
Q

Why is Nevirapine based PEP not recommended

A

almost 10% experience grade 3 or 4 hepatotoxicity and serious liver toxicity (requiring transplant)

43
Q

What medicagtions of OTC preparations should be avoided with PEPSE

A

raltegravir (and dolutegravir) = low risk of druginter actions,

Avoid concomitant use of metal cation containing antacids and multivitamins s

Dose-adjustment required with concomitant rifampicin use

44
Q

Baseline investigations when initiating PEPSE

A 
HIV test - 4th generation
Hep B sAg (if not vaccinated)
Hep B immunity
Hep C
Syphilis
STI testing 
Creatinine
ALT
Urinalysis or uPCR
Pregnancy test
45
Q

What investigations should be offered at 14 days after initiating PEPSE

A

STI testing
Creatinine - if abnormal at baseline
ALT - Only if abnormalities at baseline / Hep B or C co- infected, or on Kaletra
Urinalysis or uPCR - Only if abnormalities at baseline

Pregnancy test - if required

46
Q

What investigations should be offered at 8–12 weeks after initiating PEPSE

A 
Repeat HIV test
Repeat Syphilis test
Repeat Hep B / Hep C
STI testing - if further risk
pregnancy test - if required
47
Q

What is the advice for patients starting on PEPSE if they develop a rash or flu-like symptoms

A

skin rash or flu-like illness during or after taking PEPSE should attend for URGENT review
to exclude HIV seroconversion

48
Q

Management of individuals who repeatedly present for PEPSE or with ongoing high-risk behavior

A

Meet with a health Sexual Health Adviser
+/- psychologist
counselling around safer sex strategies

49
Q

Which patients should PrEP be recommended for?

A

HIV-negative MSM identified at increased risk of HIV acquisition through condomless anal sex in the previous 6 months + ongoing condomless anal sex

50
Q

what medication is used as PrEP

A

Truvada = Tenofovir-DF and Emtricitabine

51
Q

What is the daily PrEP regimen

A

Daily PrEP = 1 pill per day

Lead-in time for daily PrEP = 7 days

Best taken at the same time each day
With or without food

52
Q

Benefit of daily PrEP regimen

A

can miss an occasional pill and still have adequate protection

53
Q

What is the On Demand PrEP or Event Based Dosing PrEP regimen

A

Only suitable for anal sex
Really important not to miss any doses

take 2 pills 2 – 24 hours before sex
take 1 pill 24 hours later
take 1 more pill 24 hours after that

If having more sex continue to take a pill every 24 hours until you have 2 sex-free days

54
Q

For which patients is on demand / event based dosing of PrEP not recommended

A

Active hepatitis B infection

- drugs in PrEP suppress HBV - so starting and stopping PrEP can cause viral flare-ups and liver inflammation

55
Q

PrEP impact on renal function

A

Modest, but statistically significant decline in renal function with daily tenofovir - emtricitabine
Mostly reversible
Serious renal events rare

56
Q

PrEP impact on bone mineral density

A

a small decrease in BMD of 0.7–1% from tenofovir + emtricitabine
no long-term data
not associated with fractures

57
Q

Why is on demand PrEP not recommended for heterosexual vaginal intercourse

A

No studies have evaluated the efficacy of an on-demand oral PrEP regimen in heterosexual men and women

58
Q

Would PrEP interact with oral contraception

A

No

Tenofovir and emtricitabine do not affect liver enzymes

59
Q

Can PrEP be used in pregnancy or breastfeeding

A

Yes
existing data supports the safety of Tenofovir and emtricitabine in pregnancy or breastfeeding
if they are at increased risk of HIV acquisition

60
Q

What is meant by PrEP bridging to TasP

A

Use of PrEP in the HIV negative partner

until the HIV positive partner is established on ARVs for treatment as prevention = on treatment with VL <50 for 6m+

61
Q

Does PrEP prevent HIV transmission in people who inject drugs?

A

Unclear
No UK data
limited evidence from Thai study - suggests reduction in
HIV incidence

62
Q

What has been suggested as the reason that PrEP for trans-women has been less effective in studies than for cis-men or cis-women

A

poorer adherence (as measured by drug concentrations)

63
Q

Regarding PrEP use in young men (<25) what health impacts should be considered

A

Reduces BMD
Appears to be reversible
may be a particular risk for adolescents as this is a critical period for attainment of peak bone mass

64
Q

What is the advice if daily dosing of PrEP has been interrupted and anal sex is expected to occur

A

If it is less than 7 days since the last dose then PrEP can be re-started with a single dose
and continue for at least 48 hours after last sexual act

65
Q

What is the advised regimen for taking for PrEP for patients at risk from vaginal sex

A

Daily dosing

Start PrEP 7/7 before vaginal sex and continue for 7/7 after the last sexual risk

66
Q

What is the advised regimen for taking for PrEP for MSM who are also at risk from injecting drug use

A

Daily dosing advised

Take for 7/7 before and continue for at least 7/7 after the risk

67
Q

for patients who are at risk of HIV from injecting drug use - Why does PrEP need to be started 7/7 before and continued for 7/7 after

A

PrEP takes longer to achieve protective concentrations in the blood than in the GI / Anal mucosa

68
Q

for patients who are at risk of HIV from vaginal intercourse - Why does PrEP need to be started 7/7 before and continued for 7/7 after risk

A

PrEP takes longer to achieve protective concentrations in the vaginal mucosa than in the GI / Anal mucosa

69
Q

In which cases does BASHH / BHIVA recommend PrEP

A

1) - HIV-negative MSM / trans women who report condomless anal sex in the previous 6 months + on-going condomless anal sex.
2) - HIV-negative individuals having condomless sex with HIV positive partners, unless the partner has been on ART at least 6 months and viral load is <200 copies/mL

70
Q

In what circumstance does BASHH / BHIVA recommend that PrEP may be considered on a case-by-case basis

A

HIV-negative individuals considered at increased risk due to a combination of factors
• black African men / women
• Recent migrants to the UK
• Transgender women
• People who inject drugs
• Sex workers / transactional sex
• Bacterial STI or HCV in last year
• Required PEPSE in last year
• High-risk sexual behaviour - multiple condomless sex acts with partners of unknown HIV status
• Chemsex
• Group sex
• Sharing injecting equipment / injecting in an unsafe setting
• Coercive / violent power dynamics in relationships
• Precarious housing / homelessness
• Risk of sexual exploitation / trafficking

71
Q

Education prior to starting PrEP

A 
information on HIV transmission
how PrEP works
potential side effects of PrEP medication
adherence and efficacy
dosing schedule
lead-in time to protection
STI/HIV testing
other HIV prevention strategies
72
Q

What is the strongest factor linked to PrEP efficacy

A

adherence

73
Q

Possible side effects from PrEP

A 
Usually well tolerated
possible transient side effects
• diarrhoea
• headache
• vomiting
• loss of appetite
encourage to manage with simple analgesics and anti-emetics
74
Q

Signs of acute HIV infection - to warn patients about when using PrEP

A 
= seroconversion - Advise to return to clinic if concerned 
• fever
• lethargy
• Swollen lymph nodes 
• Swollen tonsils
• sore throat
• myalgia / arthralgia 
• diarrhoea
• rash
75
Q

Explanation of HIV transmission for patients before starting PrEP

A

HIV = virus
only transmitted through specific activities.
Only certain body fluids can transmit HIV from a HIV infected person - blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk
These fluids must contact a mucous membrane / damaged tissue or be directly injected into the blood

HIV mainly spread by

  • anal / vaginal sex
  • Sharing needles / drug equipment
  • mother to child during birth or breastfeeding
  • Needlestick injury
  • Blood transfusion / blood products / organ transplant from HIV infected sources
76
Q

Baseline investigations before a patient starts PrEP

A 
POCT HIV test 
HIV serology - 4th generation
Hep B 
Hep C - if risk
Syphilis
STI testing 
Creatinine + eGFR
ALT
Urinalysis or uPCR
Pregnancy test
77
Q

Advice if a patient becomes pregnant while on PrEP

A

if a patient is pregnant when starting PrEP or becomes pregnant while on PrEP
Advise continuing PrEP during pregnancy or breastfeeding if there is an ongoing risk of HIV acquisition

78
Q

In what circumstance does on demand dosing for PrEP not require a loading dose of 2 pills

A

A loading dose of two pills is required 2 - 24 hours before sex
unless the last PrEP dose was less than one week earlier in which case they can be instructed to only take one pill 2 - 24 hours before sex

79
Q

What is the advice re how to take on demand PrEP if there are multiple consecutive episodes of sex

A

loading dose = 2 pills 2 – 24 hours before sex
take 1 pill 24 hours later
take 1 more pill 24 hours after that
Continue taking every 24 hours until 48 hours after the last sexual intercourse

80
Q

What regimen of PrEP is recommended for `trans-women and trans-men
and why

A

Daily dosing

Absence of data for on-demand dosing in trans patients

81
Q

What is Intermittent dosing of PrEP?

A

Taking 4 tablets per week on intermittent days

82
Q

What monitoring is recommended whilst a patient is on PrEP

A

HIV testing - 3 monthly
STI screening - 3-monthly
HCV testing - 3-monthly - in MSM, trans women + others at on-going risk of HCV
Renal function:
- If eGFR >90 at baseline + follow up and patient <40yo - advise annual eGFR
- If eGFR 60–90 / aged >40 years or risk factors for renal impairment - monitor renal function at least 6 monthly
- If eGFR <60 - discuss the risks and benefits of continuing PrEP
Discuss contraception + assess pregnancy risk @ follow up visits

83
Q

Indications for stopping PrEP

A
  • Positive HIV test - Refer to specialist HIV service
  • Chronic HBV infection - DW Hepatitis specialist re safety of PrEP
  • a reduction in risk of HIV acquisition as defined by eligibility criteria
  • poor adherence + attempts at adherence support have failed
  • Review if eGFR falls <60 - renal input
84
Q

what drug interactions should be considered when offering PEPSE including raltegravir or dolutegravir

A

raltegravir and dolutegravir = low risk in-terms of drug–drug interactions

AVOID concomitant use of metal cation containing antacids and multivitamins if possible

85
Q

Apart from side effects, what is another reason why (PIs) such as Kaletra (lopinavir / ritonavir) or darunavir / ritonavir are not preferred options for PEPSE

A

More drug-drug interactions

e.g. interacts with contraception to reduce efficacy

Dip GUM (27 decks)

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