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DipHIV > PEP/PrEP > Flashcards

PEP/PrEP Flashcards

1
Q

iPrEx study

A
  • Phase 3 blinded, RCT, 2499 MSM + trans women
  • Randomised to Truvada or placebo
  • In those with detectable Truvada levels, 92% reduction in incidence of HIV
  • In iPrEX-OLE no seroconversions seen when drug levels compatible with taking 4 or more pills a week
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2
Q

PROUD

A
  • Phase 3, open label, randomised to receive daily dose Truvada immediately or after a deferral of 12 months
  • At interim review it was recommended everyone get the trial drug as 20 in the deferred group Vs 2 in trial group had tested positive
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3
Q

IPERGAY

A
  • Phase 3, double blind RCT in 414 mSM
  • TVD on demand or placebo
  • Regimen was double dose 2-24 hours before sex, daily dosing during period of sexual risk and then for 48 hours (2 doses) after
  • 14 in placebo Vs 2 in treatment group tested pos
  • Relative risk reduction 86%
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4
Q

DPMA and PrEP

A
  • DPMA increasing risk of getting HIV
  • PrEP largely overcomes this risk
  • However, if a woman is at increased risk of HIV, ideally not using DMPA
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5
Q

Partners PREP

A
  • Double blind placebo controlled RCT heterosexual couples Uganda + Kenya
  • TDF vs TDF-FTC vs placebo
  • Efficacy of TDF alone was 67% compared to placebo, and comparable to Truvada (75%)
  • Therefore can give TDF alone in heterosexuals where FTC contraindicated
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6
Q

Baseline assessment and testing for PrEP

A
  • HIV test (POC and 4th gen)
  • Renal and UPCR
  • Hepatitis screen
  • STI screen
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7
Q

Indication of PEP following sub-optimal PrEP

A
  • If risk through anal sex and at least 3 tablets taken in the last 7 days can restart with single dose of TVD (as will fulfil IPREX 4 doses/week)
  • If fewer than 3 doses in last 7 days -> PEP
  • In vaginal sex, consider PEP if more than 48 hours since last dose or fewer than 6 tablets in previous 7 days
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8
Q
  • Short and long term side effects of PrEP
A
  • Nausea/bloating/abdo pain/dizziness/headache usually short-lived, disappear in first month, can manage with simple analgesia or antiemetics
  • Longer term bone and renal
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9
Q

Routinely offer PEP in the following scenarios

A
  • Receptive anal sex (unless known and VL<20)
  • Insertive anal sex (unless known and VL<20)
  • Receptive vaginal sex where index HIV positive with unknown or detectable VL (consider if insertive)
  • Not recommended in any situation for fellatio/splash semen/cunnilingus
  • Occupational/other recommended if known HIV and VL unknown or detectable and sharps/mucosal splash, otherwise not recommended
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10
Q

Hep C final testing window

A
  • Could do RNA 2 weeks post exposure if high risk
  • Final testing hep C core antigen or RNA at 12 weeks or HEP C antibody at 6 months
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11
Q

When to discontinue due to missed doses of PEP

A

If more than 48 hours since last dose then discontinue

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12
Q

How effective is PEP?

A
  • No RCT as not ethical
  • Only been 1 case of HIV transmission in HCW when PEP has been used (the index case was highly treatment experienced)
  • Sexual exposure no great evidence, one observational study in Brazil MSM saw 1 seroconversion in group taking PEP Vs 10 in group not taking
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13
Q

Risk of HIV transmission equation

A

Risk of getting HIV = risk source has HIV and has detectable VL x risk transmission per exposure

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14
Q

Risk of HIV transmission per exposure from an HIV positive individual who in NOT on suppressive ART

A

Receptive anal intercourse: 1 in 90
Receptive anal intercourse with ejaculation: 1 in 65
Receptive anal intercourse without ejaculation: 1 in 170
Insertive anal intercourse not circumcised: 1 in 161
Insertive anal intercourse circumcised: 1 in 909
Receptive vaginal intercourse: 1 in 1000
Needlestick: 1 in 333
Sharing needles: 1 in 149
Mucocutaneous: 1 in 1000
Semen splash to eye, oral sex <1 in 10,000

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15
Q

Hepatitis B transmission prevention if unvaccinated and higher risk source (PWID, MSM, high prevalence country)

(If HbsAb<10 at time of exposure then rapid course vaccination)

A
  • Ultra rapid Hep B vaccination (0, 7, 21 days and 12 months)
  • If source known HBsAg+ HBIG
  • Check HBsAg and HBsAb at 12 weeks post exposure, if Abs<10 give booster
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16
Q

HIV1 and HIV2 are related to which animals viruses?

A

HIV1: simian immunodeficiency virus (SIV) in chimpanzees
HIV2: an SIV in sooty mangabeys

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17
Q

Diagnosis of HIV 2 window period

A
  • p24 antigen testing is specific for HIV 1 only, therefore if using a 4th generation where there is risk of HIV2, it is essentially working as a 3rd generation and window period is 90 days
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18
Q

If you have indeterminate serology and HIV 2 RNA not detected (best test is ROCHE qualitative RT-PCR) then what is the next test to do?

A
  • Proviral DNA (need to send to lab quickly, white cells are separated from whole blood and HIV 2 DNA that has integrated into human lymphocytes is looked for)
  • Western blot diagnostics are not performed in UK
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19
Q

Diagnosis of HIV 2

A
  • Need 3x CE marked tests
  • First 2 CE marked 4th gen tests for HIV 1 and 2 followed by CE marked antibody only test
    (If someone with a diagnosis of HIV 1 has an undetectable HIV VL and falling CD4, consider repeating HIV 2 serology and molecular tests in order to detect possibility of dual infection)
20
Q

What to do if indeterminate HIV 1 or HIV 2 serology

A

Investigate with HIV 2 proviral DNA

21
Q

When to start ART in HIV 2

A
  • It is suggested that all start
  • It is recommended where there is dual infection, primary infection, HBV, pregnancy, detectable viraemia, CD4<500, advanced HIV, OI or symptoms
22
Q

What to start ART with in HIV2

A
  • 2 NRTIs plus a second generation INSTI )BD DTG) or darunavir/ritonavir
  • Generally give BD DTG or BD DAR/rit (unless consistently aviraemic)
  • TDF or TAF/FTC is preferred backbone
  • No NNRTIs due to intrinsic resistance, 2 drug regimens not recommended
23
Q

Monitoring in HIV2, on and off treatment:

A

Off treatment: CD4 3-6 monthly (could be 6 monthly if CD4>500) and VL 6 monthly
On treatment: CD4 1, 3 and 6 months after starting and then 3-6 monthly depending on nadir CD4, if pre-treatment VL was detectable then VL at 1 month then 6 monthly

24
Q

Risk of mother to child transmission without ART in HIV1 and HIV2

A

HIV1 25-30%
HIV2 0.6-4%

25
Q

Neonatal PEP in HIV2

A
  • Low or very low risk: 2 or 4 weeks zidovudine as per HIV1
  • High risk should receive zidovudine/lamivudine/raltegravir
26
Q

ART considerations in women conceiving on ART

A
  • Generally don’t change
  • Raltegravir must be 400mg BD
  • No cobi
  • If DTG give high dose 5mg folic acid
  • No PI mono therapy
27
Q

When to start ART in pregnancy?

A
  • If VL<30,000 then as soon as able to do so in 2nd trimester
  • If VL 30,000-100,000 then at start of 2nd trimester
  • If VL>100,000 OR cd4<200 then as soon as possible even if first trimester
  • (all should have started by 24 weeks)
28
Q

What ART to start in pregnancy?

A
  • Recommended to start with TDF or ABC with 3TC or FTC, then either EFV or ATZ
  • Rilpivirine 25mg OD, RAL 400mg BD or DAR/r 600/100mg are alternatives (and this could be BD especially if any resistance), DTG 50mg if after 6 weeks
  • TAF after 1st trimester
  • Pick something INSTI based if baseline VL>100,000 or ART failing to suppress (similarly if late presenting and VL unknown)
  • In HIV2 boosted PI based regimen such as BD darunavir/r is recommended
29
Q

Management of untreated woman in labour

A
  • Stat NVP 200mg
  • Commence lamivudine 150mg BD
  • Zidovudine 300mg OD
  • Raltegravir 400mg BD
  • Commence zidovudine infusion (2mg/kg/hr loading then 1mg/kg/hr until cord clamped)
  • If pre-term labour give double dose TDF to load infant
  • If delivery not imminent, consider CS
30
Q

What to do if woman is Hep A non immune and has been diagnosed with hepatitis B in pregnancy?

A

Wait until after 1st trimester and then vaccinate against hepatitis A
- 0 and 6 months if CD4>300
- 0, 1 and 6 months if CD4<300

31
Q

ART and testing considerations if diagnosed with HIV and Hepatitis B in pregnancy

A
  • Ensure TDF or TAF (can have TAF after 1st trimester)
  • Ideally FTC as shown to have slightly better anti-viral efficacy to 3TC but either ok
  • Can omit FTC/3TC if clinical or genotypical evidence of resistant HBV (and do not use these drugs as the sole anti HBV drug)
  • Test for Hep A, C and delta
    HBV DNA, e antigen status as well as ALT/AST, Alb, INR, chronic liver disease screen and tests to determine hepatitis inflammation/fibrosis
32
Q

Neonatal hepatitis B transmission prevention:

A
  • Mode of delivery makes no difference, breastfeeding makes no difference
  • All babies must be given HBV immunisation within 24 hours of delivery then follow normal infant vaccine schedule
  • Give HBIG if:
    -> Maternal HBV DNA>10 log 6
    -> And/or woman is HBeAg positive
    -> Woman Anti-HBe negative or unknown
33
Q

Rate of VT of hep B if HbsAg and HbeAg positive?

A

70-90%

34
Q

Rate of VT of hep B if HbsAg pos and HbeAg neg?

A

10-40%

35
Q

Risk of VT of Hepatitis C and how to prevent it

A
  • Risk is around 5% in mono infection, probably higher with HIV co-infection and if HCV viraemic
  • Nothing can do to prevent it
  • Ensure vaccinated against hep B and A
36
Q

Recommendations for invasive antenatal testing if VL is detectable

A
  • Start ART including raltegravir
  • Stat dose NVP 2-4 hours before procedure
  • Don’t do EVC if detectable
37
Q

Recommended mode of delivery depending on HIV VL

A
  • Make a decision with the 36 week VL
  • VL<50 any mode of delivery supported
  • VL 50-399: pre-labour CS at week 38-39 should be considered
  • VL>400 PLCS recommended week 38-39
38
Q

Management of spontaneous rupture of membranes

A
  • VL<50: immediately start induction aiming for birth within 24 hours
  • VL 50-399: recommend immediate CS although take other factors into account
  • VL>400: immediate CS
39
Q

When to use intrapartum IV zidovudine

A
  • VL>1000 presenting in labour or with SROM admitted to PLCS
  • Consider where VL 50-1000
  • Untreated women (as well as the other meds)
40
Q

Who is very low risk for VT
(2 weeks zidovudine mono therapy)

A

If all 3 of the following:
- On ART for longer than 10 weeks
- 36 week VL<50
- Two documented HIV VL<50 during pregnancy at least 4 weeks apart

41
Q

Low risk for VT
(4 weeks zidovudine mono therapy)

A
  • Criteria for very low risk are not all fulfilled but HIV VL at 36 weeks <50
  • Infant born prematurely <34 weeks but most recent maternal HIV VL<50
42
Q

Neonatal prep when high risk for VT (HIV VL known to be>50 on day or birth, uncertainty about maternal adherence of VL not known)

A
  • 2 weeks Nevirapine
  • 4 weeks zidovudine and lamivudine
  • start as soon as possible and within 4 hours

(HIV 2 then zidovudine, lamivudine and raltegravir)

43
Q

If not breastfed, how long postpartum will a HIV RNA/DNA detect 100% infections?

A
  • 3 months
  • HIV RNA or DNA similar sensitivities
  • RNA requires 1 ml of blood, DNA can be done on less
  • DNA is better as may get false neg RNA if maternal ART with agents that cross the placenta, but not always available, if RNA detected confirm with DNA
  • Always get maternal sample same time to ensure the primers being used can detect the type of HIV
  • If cannot amplify the maternal DNA despite 4 different primer sets then the 18 month antibody test is particularly important
44
Q

Non breastfed testing:

A
  • During first 48 hours and prior to discharge
  • (2 weeks if high risk delivery)
  • 6 weeks
  • 12 weeks
  • 22-24 month antibody test (engagement in care should continue until at least 18 months)
45
Q

Breastfed baby testing

A
  • During the first 48 hours and prior to discharge
  • At 2 weeks
  • Monthly for duration of breastfeeding
  • At 4 and 8 weeks after cessation of breastfeeding
46
Q

Preterm SROM management

A
  • Management of preterm SROM at >34 weeks is same as above except that those 34-37 weeks will require group B strep prophylaxis in line with national guidelines
  • When premature SROM occurs <34 weeks:
    o IM steroids
    o Optimise HIV VL
    o MDR discussion about timing and mode of delivery

DipHIV (8 decks)

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