HIV prevention - Revision history

Aidan at 23:41, 14 August 2019

2019-08-14T23:41:07Z

← Older revision		Revision as of 23:41, 14 August 2019
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	= Preventing HIV =

	== Background ==		= Background =

	* HIV elimination is possibly with the present tools, even without a cure or vaccine		* HIV elimination is possibly with the present tools, even without a cure or vaccine
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	** Pharmacologic		** Pharmacologic

	== Non-pharmacologic approaches ==		= Non-pharmacologic approaches =

	* Condoms		* Condoms
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	* Circumcision		* Circumcision

	== Pharmacologic approaches ==		= Pharmacologic approaches =

	=== Treatment as Prevention (TasP) ===		== Treatment as Prevention (TasP) ==

	* Basics		* Basics
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	** 93% lower risk (HR 0.07) from your linked partner, with no linked infections when partner was virologically suppressed		** 93% lower risk (HR 0.07) from your linked partner, with no linked infections when partner was virologically suppressed

	=== Post-Exposure Prophylaxis (PEP) ===		== Post-Exposure Prophylaxis (PEP) ==

	* Basics		* Basics
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	** Counsel patients on STIs, substance use, etc		** Counsel patients on STIs, substance use, etc

	=== Pre-Exposure Prophylaxis (PrEP) ===		== Pre-Exposure Prophylaxis (PrEP) ==

	* Basics		* Basics
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	*** Screen for drug and alcohol abuse		*** Screen for drug and alcohol abuse

	=== Other modes of prevention ===		== Other modes of prevention ==

	* On-demand PrEP, with each encounter		* On-demand PrEP, with each encounter
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	** Rx for 28 days of Truvada that they can start when needed after an exposure		** Rx for 28 days of Truvada that they can start when needed after an exposure
	** On exposure, start their own treatment and arrange followup in clinic		** On exposure, start their own treatment and arrange followup in clinic

			[[Category:HIV]]

Aidan: Aidan moved page RNA Human immunodeficiency virus HIV prevention to HIV prevention without leaving a redirect

2019-08-14T23:40:46Z

Aidan moved page RNA Human immunodeficiency virus HIV prevention to HIV prevention without leaving a redirect

← Older revision	Revision as of 23:40, 14 August 2019
(No difference)

Maintenance script: Imported from text file

2019-08-11T18:05:57Z

Imported from text file

New page

= Preventing HIV =

== Background ==

* HIV elimination is possibly with the present tools, even without a cure or vaccine
* Strategies
** Non-pharmacologic
** Pharmacologic

== Non-pharmacologic approaches ==

* Condoms
* Safe sexual practices
* Circumcision

== Pharmacologic approaches ==

=== Treatment as Prevention (TasP) ===

* Basics
** Screen everyone
** Treat everyone at time of diagnosis
** Treated individuals are less likely to transmit
*** U=U: undetectable equals untransmittable
** Lowers the community viral load
* [https://dx.doi.org/10.1056%2FNEJMoa1600693 Cohen et al. NEJM 2016]
** 1763 serodiscordant couples in 9 countries who received early care (at time of diagnosis) or delayed care (wait until CD4 drops)
** Outcome was transmission to their HIV-negative partners
** 93% lower risk (HR 0.07) from your linked partner, with no linked infections when partner was virologically suppressed

=== Post-Exposure Prophylaxis (PEP) ===

* Basics
** Potential HIV exposure
** Short-term ARVs
** Prevents HIV
* Reactive approach
* Guidelines exist, including [https://doi.org/10.1503/cmaj.170494 Canada's PEP guideline 2017]
* Exposures
** Sexual
*** Consensual
**** Heterosexual
**** Homosexual
*** Non-consensual
**** Heterosexual
**** Homosexual
** Non-sexual
*** Needlestick
*** Other
* Approach
** Did an exposure occur?
*** Infected body fluid or mucosa that comes into contact with mucosa, blood, or broken skin
**** Infectious: blood, genital secretions, amniotic fluid, breast milk, CSF, pleural pericard, peritoneal synovial
**** Non-infectious: urine, saliva, sweat, emesis, feces
*** Details often hazy, with drugs, alcohol, and trauma
*** Often end up treating the worst-case scenarios
** What is the risk per exposure to known HIV contact?
*** Very high risk
**** Blood transfusion 92.5%
*** High risk
**** Receptive anal intercourse 1.38%
**** Needle sharing 0.63%
**** Percutaneous needle-stick injury 0.23%
*** Moderate risk
**** Anal (insertive) 0.11%
**** Vaginal (receptive) 0.08%
**** Vaginal (insertive) 0.04%
*** Low risk (no specific numbers)
**** Oral sex (giving)
**** Oral sex (receiving)
**** Oral-anal contact
**** Sharing sex toys
**** Blood on compromised skin
* Treatment
** Start within 72h, use 3 drugs, treat for 28 days
*** Truvada + raltegravir; but any will work
*** Avoid drugs in pregnant or breastfeeding women
** Screen for
*** STIs
*** HBV and HCV, maybe HAV (for immunization)
*** Pregnancy
*** Trauma
** Follow-up in 4-6 weeks then 4 months for repeat testing
** Counsel patients on STIs, substance use, etc

=== Pre-Exposure Prophylaxis (PrEP) ===

* Basics
** Give ARV to HIV-negative individuals who are at risk
** If they are exposed, they won't seroconvert
* Proactive approach
* Only works if you take the pills (70-90% effective), but adherence is poor
* Guidelines exist, including [https://doi.org/10.1503/cmaj.170494 Canada's PrEP guideline 2017]
* Eligibility
** MSM: multiple unprotected exposures, HIV+ partner, sex work
** IVDU who share needles
** Women: high number of unprotected partners, HIV+ partner, sex work
* Baseline
** HBsAb, HBsAg, and HBcAb; HCV-Ab; and HAV, so you can vaccinate
** STI screening
*** Syphilis, chlamydia, and gonorrhea
*** Urethral, pharyngeal, and rectal
* Treatment
** Truvada 1 tablet daily for 3 months at a time, without repeats
** Counsel on condom use and side effects
*** Needs to be taken for 7 days before it is effective
*** Connect to mental health and other services, if indicated
** Follow-up every 3-4 months
*** Ask about HIV and STI symptoms, and screen them
*** Side effects of medications
*** Reassess need for PrEP
*** Screen for drug and alcohol abuse

=== Other modes of prevention ===

* On-demand PrEP, with each encounter
** 2 tabs 2-24h before sex, then 1 tab at 24h after and 48h after
** Limited utility, more cumbersome
* PEP-in-pocket (PIP)
** Very infrequent condomless sex, 0 to 4 exposures per year
** Rx for 28 days of Truvada that they can start when needed after an exposure
** On exposure, start their own treatment and arrange followup in clinic