Basic HIV Course for Health Professionals Session 2

Basic HIV Course for Health Professionals Session 2: Prevention of HIV and AIDS

Learning Objectives By the end of this session participants should be able to: • • • Explain prevention measures for HIV Demonstrate condoms use and application Describe the benefits of circumcision Explain post exposure prophylaxis (PEP) Explain pre-exposure prophylaxis (Pr. EP)

Group Discussion What are different ways of preventing HIV infection?

Introduction to Prevention (1) • Multi-pronged approach with goals that include protecting individual, partners, community • Several methods have proven highly effective in reducing risk of HIV: • use of male and female condoms • antiretroviral medication as pre-exposure prophylaxis (Pr. EP) • voluntary male medical circumcision (VMMC) • behaviour change interventions

WHO should be offered HIV prevention services All HIV negative women, including adolescent girls and sex workers HIV negative partners and other men HIV positive persons WHAT HIV prevention option should be offered Basic Prevention Package HTS services Couples Counselling and partner testing Screen and treat STIs Safe sex education PEP Pr. EP as applicable &available Basic Prevention package Voluntary Medical Male Circumcision (VMMC)and communication for men Treatment as prevention HTS, couples counselling and partner testing, Linkage to Care, ART and VL suppression Remember condoms are recommended for all couples regardless of HIV status

Introduction to Prevention (2) • Risk exists if body fluid known to contain HIV comes into contact with partner’s mucous membranes or blood stream • Brief summary of prevention methods to be covered further in this session: • • • A – Abstinence B – Be faithful C – Condomize/Circumcise D – Delayed sexual debut E – Education/ Empowerment

How to Put on a Male Condom

Activity: Using a Male Condom

Female Condom (1) • Thin, soft, loose-fitting sheath made from Natural Rubber Latex worn inside vagina • Flexible octagonal ring at open end • Donut shaped soft polyurethane foam at closed end used to insert condom in vagina and hold it in place during intercourse • Octagonal outer ring at open end remains outside vagina and covers part of external genitalia • Insert female condom into vagina before sex • Holds man’s sperm after ejaculation thus helping prevent unintended pregnancy and STIs

Female Condom (2)

Cupid Female Condom • The Cupid female condom features a large, circular sponge. The sponge helps anchor the condom during use. -Polyurethane sponge is used as retention feature that helps easy insertion, once inserted holds the condom in place during use and prevent pull-out -The donut shaped sponge retainer absorbs semen after ejaculation and avoids spillage during removal of condom after use.

How to use Ring Female condom 1. Insert the female condom 2. Squeeze the ring at the closed end of the pouch with your middle finger and thumb and insert it into your vagina like a tampon 3. Place your index finger inside the condom and push the ring up as far as it will go 4. Don't allow the condom to twist

How to use Cupid Female Condom

How to Use a Female Condom (2)

Cautions: Optimal Use of Female Condom • Store in cool dry place away from heat and direct sunlight • Female condoms are easy to use, but may need practice for insertion • Trim nail of finger used for insertion of female condom to avoid tearing it • Natural Rubber Latex may cause allergic reaction • Do not use: • with oil based lubricants • male and female condoms together • condom after expiry date

Circumcision • Male circumcision is surgical removal of foreskin, the retractable fold of tissue that covers head of penis • Voluntary medical male circumcision (VMMC) is one of the most powerful and cost-effective HIV prevention tools at hand • Studies showed it reduces man's risk of acquiring HIV from a female partner by up to 60 percent, increasing to around 75 percent over time • Correct and consistent use of condoms form a crucial part of VMMC education

HIV entry point

Benefits of Circumcision • Additional line of defence against STIs, including HIV • Circumcised men have fewer cells to transport HIV to CD 4 T cells • Removing foreskin gets rid of wet, warm and dark environment between penis and foreskin that can sustain viruses • Being circumcised reduces female partner’s risk of cervical cancer • Risk reduction counselling is still required within the circumcised groups

Post Exposure Prophylaxis (PEP) • PEP =refers to ARV drugs that are given to a person following exposure to blood products or penetrative sex or sexual assault • An exposure that may place one at risk of HIV includes: • Percutaneous injury (needle stick or cut with sharp object) – injury just cutting through skin • Contact of infectious bodily fluid with mucosal membranes or non-intact skin • A human bite from an HIV positive person, especially if blood is present in mouth

Rationale behind Post Exposure HIV Prophylaxis • Infection in blood does not occur immediately - brief window of opportunity during which post exposure antiretroviral intervention might prevent viral replication • PEP is most effective when started within first 24 -36 hours of exposure and up to 72 hours • Best given within first 1 -2 hours after exposure This Photo by Unknown Author is licensed under CC BY-NC-ND

Pathogenesis • Infection is not immediate • Dendritic cell is the initial target • Over 24 -48 hrs migration to regional lymph nodes • Virus detectable in blood within 5 days • Widespread dissemination follows

Nature of Exposure Occupational exposure • Occurs at work although should be preventable • Needle-stick injury • Cuts from dental, surgical, lab instruments • Splash of blood or body fluid in eye, nose, mouth or skin during medical or lab procedures Non-occupational exposure • Condom burst • Sexual assault/Rape • Unprotected sexual intercourse This Photo by Unknown Author is licensed under CC BY-SA

Risk Assessment: Evaluation of the Exposure • Date and time of exposure • Details of procedure being performed • Information regarding the exposure • (i. e. what kind of fluid, skin cut) • • What is source’s HIV status? Risk factors for HIV? Is hepatitis B or C status known? Were gloves and goggles worn? This Photo by Unknown Author is licensed under CC BY-NC-SA

High Risk PEP • Source patient has AIDS or a high VL > 100 000 copies/ml • Hollow-bore needle used in a vein or an artery • Deep cuts from dental, surgical and lab instruments • Untreated mother-to-child-transmission, risk (2040%) • Exposure to sexual fluids • Exposure to any blood-stained fluid, tissue or material

Low Risk PEP • Superficial needle stick injury • Solid needle • Splash of blood or body fluid in eye, nose, mouth or skin during medical, lab procedures • Non-intact skin – chapped, abraded dermatitis • Source patient HIV negative but has clinical features suggest sero-conversion illness

No Risk PEP • Healthcare worker is HIV positive • Intact skin • Contact with the following fluids: • Saliva • Non-bloody urine or faeces • Vomitus • Source patient was HIV negative NB! PEP is not indicated in these instances

Evaluation of the Source • Obtain HIV status from source of exposure • If source unknown, unavailable, or refuses testing after counselling, assume source is sero-positive • No risk – HIV negative • Lower risk – HIV positive, VL undetectable or low titre Higher risk – Detectable viral load: higher VL = greater risk, low CD 4, AIDS or advanced disease, or primary HIV infection • Unknown status– assess on case by case basis

What to Do When Exposed to HIV Infected Blood? (1) Prompt measures: • Do not panic • Do not put cut/pricked finger in mouth • Rinse under running water and clean wound • Notify health and safety officer • complete injury on duty-form, keep a copy • Obtain medical attention immediately • Pre-test counselling This Photo by Unknown Author is licensed under CC BY-NC-ND

What to Do When Exposed to HIV Infected Blood? (2) • Baseline bloods: HIV-ELISA, RPR, HBV and HCV serology • Post-test counselling • Start ART immediately if protection indicated • Unless PEP not indicated: • low risk/intact skin • Pt positive already • Pt already on treatment

What to Do When Exposed to HIV Infected Blood? (3) In situations where there is a high suspicion that the patient may be in the window period, consider HIV PCR testing

Prevention of Primary Infection Interventions to prevent HIV infection include: • Reducing heterosexual transmission • Involving men in interventions to reduce transmission • Addressing gender issues • Keeping adolescents in school, delaying sexual activity • Providing youth-friendly services at health facilities • Integrating sexual and reproductive health services, and providing comprehensive management of STIs • Counselling on risk of unintended pregnancies, STIs and HIV

PEP management • PEP should be administered as soon as possible following the exposure • It should be administered within 72 hours • It may be considered up to 7 days after exposure in exceptional cases e. g. in high-risk exposures • It is associated with decreased efficacy if administered 72 hours after the exposure • All PEP regimens should be administered for 28 days • The person should be HIV negative

Pre-Exposure Prophylaxis (Pr. EP) • Pr. EP = use of antiretroviral drugs by HIVnegative people before potential HIV exposure to prevent acquisition of HIV • Currently, Pr. EP is offered to all sex workers and men-who-have-sex-with-men (MSM) • Will be expanded to include other high-risk populations e. g. , adolescent girls

NB: A negative HIV test is required before Pr. EP drugs can be prescribed at initiation and with every prescription refill, and when restarting after a discontinuation.

Prescription of drugs • Truvada (TDF/FTC) 1 tablet PO daily • At initiation – give 1 -month supply • At 1 month – repeat HIV test, give 3 -month supply • Every 3 months – repeat HIV test, give 3 -monthly supply

Who is for Pr. EP • Those with HIV-positive sexual partners that are virological not suppressed All of these groups include adolescents • Partners with unknown HIV status and sex workers. Those • Recent STIs especially vulnerable • Multiple sexual partners are MSM and young adolescent girls. • Inconsistent or no condom use • Recurrent Post Exposure Prophylaxis users (PEP) • Serodiscordant couples that are trying to conceive • History of sex while under influence of alcohol • Those who are share injecting needles and drug preparation equipment

Contraindications for Pr. EP Use • Pre-existing HIV infection • Creatinine clearance < 60 m. L/min • Adolescents <35 kg or <15 years of age, who are not Tanner stage 3 (sexual maturity rating) or greater • Unwilling/unable to adhere to daily Pr. EP • Pregnancy (as per current Truvada package insert)

Clinical Screening Investigations (Baseline) for Pr. EP Investigation HIV test (using algorithm in HTS guidelines) Creatinine clearance Purpose Assessment of HIV status To identify pre-existing renal disease Hepatitis B surface antigen To identify: (HBs. Ag)* • undiagnosed hepatitis B infection • those eligible for vaccination against hepatitis B ALT if HBs. Ag positive To determine if vaccination against HBV infection or treatment of HBV is required Urine pregnancy test To identify if client is pregnant RPR To diagnose syphilis infection for treatment Syndromic STI screening To diagnose and treat STI Clients with acute/chronic hepatitis B infection can initiate Pr. EP but will need liver function monitoring

Pr. EP Follow up and Monitoring Confirmation of HIVnegative status Address side effects and adherence counselling Creatinine clearance test At 1 month, then every 3 months Every visit At 1 month, then every 3 months for first year

PMTC • The HIV-related mortality rate is very high in the first year of life for untreated HIV-infected infants, with effective PMTCT programme, the yield of HIV-positive children is likely to shift outside of PMTCT services. • It is therefore important to integrate HIV testing into other child health programmes and to develop a systematic process to identify and prioritise high-yield testing among infants and children. HTS for children and infants

HTS for infants and children should encompass • early infant diagnosis (EID) for all HIV-exposed infants • testing all infants and children presenting with indicator conditions, such as failure to thrive, oral candidiasis, skin conditions, chronic cough, etc. • offering HTS to all medical admissions to wards • testing all children receiving TB and malnutrition treatment • testing all children of adults and siblings who are receiving HIV services • testing all children accessing services for orphans and vulnerable children (OVC), especially if a parent has died

Any Questions? Thank you!