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Dip GUM > PEPSE / PrEP > Flashcards

PEPSE / PrEP Flashcards

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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
Alternative to raltegravir in PEPSE for patients who cannot take it
dolutegravir | integrase inhibitor
26
Why is abacavir not reccomended for PEPSE
8% of patients will have a hypersensitivity reaction Requires HLA-B * 570 screening test before initiation Abacavir = NRTI
27
Rationale behind PEPSE
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
28
What should be considered regarding PEPSE if a person has had multiple exposures within 72 hours
cumulative risk should be considered
29
HIV prevention strategies
``` 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) ```
30
Advice regarding PEPSE if source HIV status is unknown
Attempt to contact partner and arrange testing of them - then stop PEPSE if they test negative
31
Is PEPSE recommended if the source HIV status is unknown but they are from a risk-group or country of high HIV prevalence (> 1%)
``` Routinely recommend for: - Receptive anal sex Consider for : - Insertive anal sex - Receptive vaginal sex - Insertive vaginal sex - Sharing of injecting equipment ```
32
In what circumstance would PEPSE be recommend when the source is known HIV positive with an undetectable VL ( < 200)
Source does not have a confirmed VL < 200 for >6 months
33
Regarding a patient started on PEPSE - what information should be obtained from a HIV positive source?
plasma HIV viral load resistance profile treatment history of the source
34
What is the risk of HIV transmission from a semen splash to the eye
no documented HIV transmissions via this route
35
Is PEPSE recommended ollowing fellatio with ejaculation
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
Is PEP recommended for a needlestick injury from a needle found in the community e.g. on the street
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
what is the timeframe for HIV becoming non-viable | e.g. on an abandoned needle in the community
HIV becomes non-viable within a couple of hours - once the blood has dried viable HIV cannot be detected after 24 h
38
Items to discuss with individual initiating PEPSE:
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
Is PEP recommended after human bites
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
Is PEPSE recommended after sexual assault
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
Duration of PEPSE
28 days
42
Why is Nevirapine based PEP not recommended
almost 10% experience grade 3 or 4 hepatotoxicity and serious liver toxicity (requiring transplant)
43
What medicagtions of OTC preparations should be avoided with PEPSE
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
Baseline investigations when initiating PEPSE
``` 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
What investigations should be offered at 14 days after initiating PEPSE
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
What investigations should be offered at 8–12 weeks after initiating PEPSE
``` Repeat HIV test Repeat Syphilis test Repeat Hep B / Hep C STI testing - if further risk pregnancy test - if required ```
47
What is the advice for patients starting on PEPSE if they develop a rash or flu-like symptoms
skin rash or flu-like illness during or after taking PEPSE should attend for URGENT review to exclude HIV seroconversion
48
Management of individuals who repeatedly present for PEPSE or with ongoing high-risk behavior
Meet with a health Sexual Health Adviser +/- psychologist counselling around safer sex strategies
49
Which patients should PrEP be recommended for?
HIV-negative MSM identified at increased risk of HIV acquisition through condomless anal sex in the previous 6 months + ongoing condomless anal sex
50
what medication is used as PrEP
Truvada = Tenofovir-DF and Emtricitabine
51
What is the daily PrEP regimen
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
Benefit of daily PrEP regimen
can miss an occasional pill and still have adequate protection
53
What is the On Demand PrEP or Event Based Dosing PrEP regimen
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
For which patients is on demand / event based dosing of PrEP not recommended
Active hepatitis B infection | - drugs in PrEP suppress HBV - so starting and stopping PrEP can cause viral flare-ups and liver inflammation
55
PrEP impact on renal function
Modest, but statistically significant decline in renal function with daily tenofovir - emtricitabine Mostly reversible Serious renal events rare
56
PrEP impact on bone mineral density
a small decrease in BMD of 0.7–1% from tenofovir + emtricitabine no long-term data not associated with fractures
57
Why is on demand PrEP not recommended for heterosexual vaginal intercourse
No studies have evaluated the efficacy of an on-demand oral PrEP regimen in heterosexual men and women
58
Would PrEP interact with oral contraception
No | Tenofovir and emtricitabine do not affect liver enzymes
59
Can PrEP be used in pregnancy or breastfeeding
Yes existing data supports the safety of Tenofovir and emtricitabine in pregnancy or breastfeeding if they are at increased risk of HIV acquisition
60
What is meant by PrEP bridging to TasP
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
Does PrEP prevent HIV transmission in people who inject drugs?
Unclear No UK data limited evidence from Thai study - suggests reduction in HIV incidence
62
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
poorer adherence (as measured by drug concentrations)
63
Regarding PrEP use in young men (<25) what health impacts should be considered
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
What is the advice if daily dosing of PrEP has been interrupted and anal sex is expected to occur
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
What is the advised regimen for taking for PrEP for patients at risk from vaginal sex
Daily dosing | Start PrEP 7/7 before vaginal sex and continue for 7/7 after the last sexual risk
66
What is the advised regimen for taking for PrEP for MSM who are also at risk from injecting drug use
Daily dosing advised | Take for 7/7 before and continue for at least 7/7 after the risk
67
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
PrEP takes longer to achieve protective concentrations in the blood than in the GI / Anal mucosa
68
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
PrEP takes longer to achieve protective concentrations in the vaginal mucosa than in the GI / Anal mucosa
69
In which cases does BASHH / BHIVA recommend PrEP
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
In what circumstance does BASHH / BHIVA recommend that PrEP may be considered on a case-by-case basis
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
Education prior to starting PrEP
``` 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
What is the strongest factor linked to PrEP efficacy
adherence
73
Possible side effects from PrEP
``` Usually well tolerated possible transient side effects • diarrhoea • headache • vomiting • loss of appetite encourage to manage with simple analgesics and anti-emetics ```
74
Signs of acute HIV infection - to warn patients about when using PrEP
``` = seroconversion - Advise to return to clinic if concerned • fever • lethargy • Swollen lymph nodes • Swollen tonsils • sore throat • myalgia / arthralgia • diarrhoea • rash ```
75
Explanation of HIV transmission for patients before starting PrEP
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
Baseline investigations before a patient starts PrEP
``` 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
Advice if a patient becomes pregnant while on PrEP
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
In what circumstance does on demand dosing for PrEP not require a loading dose of 2 pills
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
What is the advice re how to take on demand PrEP if there are multiple consecutive episodes of sex
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
What regimen of PrEP is recommended for `trans-women and trans-men and why
Daily dosing | Absence of data for on-demand dosing in trans patients
81
What is Intermittent dosing of PrEP?
Taking 4 tablets per week on intermittent days
82
What monitoring is recommended whilst a patient is on PrEP
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
Indications for stopping PrEP
- 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
what drug interactions should be considered when offering PEPSE including raltegravir or dolutegravir
raltegravir and dolutegravir = low risk in-terms of drug–drug interactions AVOID concomitant use of metal cation containing antacids and multivitamins if possible
85
Apart from side effects, what is another reason why (PIs) such as Kaletra (lopinavir / ritonavir) or darunavir / ritonavir are not preferred options for PEPSE
More drug-drug interactions e.g. interacts with contraception to reduce efficacy

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