Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) Post-exposure prophylaxis for HIV 3 Post-exposure prophylaxis for HIV is a set of comprehensive actions aimed at preventing infection in the exposed person. It includes first aid care, counselling and risk assessment, HIV testing following informed consent, and – depending on the risk assessment – the provision of a short course (28 days) of antiretroviral drugs, with follow-up and support. Step 1. First aid Provide immediate first aid care for the exposure site, as described above. Step 2. Report and evaluation After the incident, the exposed person should be referred to a trained service provider, who can give counselling, evaluate the risk of HIV transmission having occurred, and decide on the need to prescribe antiretroviral (ARV) medications to prevent HIV infection. The incident should be reported for further evaluation, according to national requirements regarding recording and notification of occupational injuries and diseases. The recommendation for HIV post-exposure prophylaxis is based on an evaluation of the risk of infection according to the type of exposure and the HIV status of the source (see Table 8.3). Table 8.3. Recommendations for HIV post-exposure prophylaxis Type of exposure Source known HIV-positive Source of unknown HIV status Source known HIV-negative Percutaneous, severe (e.g. injury with large hollow-bore needle, deep puncture, visible blood on device, needle used in artery or vein) Two-drug regimen a Consider HIV prevalence in population or subgroup PEP not recommended, unless there is risk that source is in window period c Percutaneous, not severe (e.g. injury with small-bore or solid needle, superficial injury) Two-drug regimen a PEP not recommended PEP not recommended Splash on non-genital mucous membrane or non-intact skin, severe (e.g. exposure to large volume of blood or semen) Two-drug regimen a Consider HIV prevalence in population or subgroup PEP not recommended, unless there is risk that source is in window period Splash on non-genital mucous membrane or non-intact skin, not severe (e.g. exposure to small volume of blood or semen, or to less infectious fluid, such as cerebrospinal fluid) PEP not recommended; two-drug regimen if circumstances require b PEP not recommended PEP not recommended a b C Three drugs are recommended in certain settings; see discussion on choice of regimen in text. Although PEP is not recommended, it is inappropriate to withhold PEP if the exposed person insists. In this case the two drug regimen is given. Recent HIV infection not detected with antibody test Prevention of Infection Chapter 8-18
Male circumcision under local anaesthesia Version 3.1 (Dec09) Post-exposure prophylaxis is not indicated: 1. if the exposed person is already HIV-positive from a previous exposure; 2. in the context of chronic exposure (e.g. repeated exposure to HIV from unprotected sexual intercourse with a known HIV-positive partner); 3. if the exposure poses no risk of transmission, e.g.: • exposure of intact skin to potentially infectious body fluids; • exposure to non-infectious body fluids (faeces, saliva, urine, sweat); • exposure to body fluids from a person known to be HIV-negative, unless the source person is identified as being at high risk of having been recently infected and currently within the window period for seroconversion. Step 3. Testing and counselling • If testing is available, the exposed person should be offered the chance to be tested for HIV and receive appropriate counselling. The person should always have the choice to refuse testing. • Do not delay starting ARVs for PEP while waiting for HIV test results. The exposed person could start taking ARVs for PEP immediately, and stop the treatment if the test results reveal that he or she is already HIVpositive. • Antiretroviral drugs for PEP should be started as soon as possible and in any case within 72 hours after exposure. • The drugs should be taken continuously for 28 days. • Each circumcision clinic should either have the necessary drugs in stock or know where they can be obtained, so that treatment can be started within 72 hours. • Whenever possible, the source patient should also be tested, with his or her informed consent. If the test results show that the source person is negative, PEP can be stopped. • Counselling should include provision of information on the importance of adhering to treatment, and information on HIV prevention in general and in the workplace. The person should be advised to use condoms, and not to donate blood or organs for up to 6 months after exposure. • Women of childbearing age should be advised to use contraception, and alternatives to breastfeeding should be discussed with women currently feeding their infants. There is a high risk of transmitting HIV to the infant if the mother becomes infected during breastfeeding. Step 4. Antiretroviral medications for post-exposure prophylaxis If national guidelines on post-exposure prophylaxis exist, these should be followed. If not, WHO recommendations may be applied. WHO recommends a two-drug PEP regimen, unless there is suspicion or evidence of drug resistance. The standard PEP regimen consists of two nucleoside reverse transcriptase inhibitors (NRTIs). The possible regimens are given in Table 8.4. Prevention of Infection Chapter 8-19
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Manual for Male Circumcision under Local Anaesthesia

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