Manual for Male Circumcision under Local Anaesthesia

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Male circumcision under local anaesthesia Version 3.1 (Dec09) Table 8.4 Recommended two-drug PEP regimens a Preferred regimens Alternative regimens zidovudine (ZDV) + lamivudine (3TC), or stavudine (d4T) + 3TC tenofovir disoproxil fumarate (TDF) + 3TC, or TDF + emtricitabine (FTC) a a These combinations are currently commercially available as fixed-dose combinations. Note that non-NRTIs are not recommended for PEP. In regions where the prevalence of drug resistance is above 15%, or when there is suspicion that the virus could be resistant to one or more of the drugs included in the standard PEP regimen, a third drug – a protease inhibitor – should be added to the two chosen NRTIs. In this situation, it is recommended to consult an HIV expert. Table 8.5 Recommended three-drug PEP regimens a Preferred regimens ZDV + 3TC + LPV/r Alternative regimens 1. ZDV + 3TC + SQV/r or ATV/r or FPV/r 2. TDF + 3TC + SQV/r or ATV/r or FPV/r 3. TDF + FTC + SQV/r or ATV/r or FPV/r 4. d4T + 3TC + SQV/r or ATV/r or FPV/r a ZDV: zidovudine; 3TC: lamivudine; LPV/r: lopinavir/ritonavir; SQV/r: saquinavir/ritonavir; ATV/r: atazanavir/ritonavir; FPV/r: fosamprenavir/ritonavir; d4T: stavudine; TDF: tenofovir; FTC: emtricitabine. • Women of childbearing age not using reliable contraception should not be prescribed medications such as the combination didanosine + stavudine. They should be offered a pregnancy test before starting the PEP regimen. • Lactating women should be aware that ARVs are excreted in breast milk, and that the virus itself can be transmitted during breastfeeding • When and where safe and feasible, alternative feeding options should be discussed with breastfeeding mothers. Step 5. Follow-up and testing Follow-up visits should aim to support the person’s adherence to PEP, prevent or treat side-effects of the medicines, and detect seroconversion, if it occurs. The following steps are recommended: • There should be regular follow-up for the first six weeks after starting PEP to support good adherence. • Perform HIV-antibody testing at baseline, 6–12 weeks and six months after exposure. • Perform HIV-antibody testing if the person develops any illness compatible with an acute retroviral syndrome. • Advise exposed persons to take precautions to prevent secondary transmission during the follow-up period. This includes: - avoiding pregnancy and seeking safe alternatives to breastfeeding; - avoiding donating blood, tissue or sperm; Prevention of Infection Chapter 8-20
Male circumcision under local anaesthesia Version 3.1 (Dec09) - using condoms during sexual intercourse, until the test at six months confirms that the exposed person remains seronegative. • Evaluate exposed persons taking PEP within 72 hours after exposure and monitor for drug adherence and possible drug-related side-effects and toxicity for at least two weeks. • If the person develops HIV antibodies, he or she should be referred for treatment, care and support. The incident report and the evaluation of the risk of exposure (see Step 2) should also lead to quality control and evaluation of working safety conditions. Appropriate correctional measures (such as strengthening adherence to standard precautions, if relevant) should be taken to prevent other exposures to HIV and other bloodborne pathogens Clinic staff should know their HIV status It is advisable for all clinic staff who carry out surgical procedures to have an HIV test at periodic intervals, in accordance with national HIV testing guidelines. If a health care worker is known to have recently had a negative HIV test, then post-exposure prophylaxis can be started immediately, if relevant, following exposure to potentially infected blood. In addition, health care workers would be showing leadership in the context of national campaigns to increase awareness of HIV status. REFERENCES 1 2 3 World Health Organization. Sharp injuries. Geneva; 2005 (Environmental Burden of Diseases Series, No. 11). World Alliance for Patient Safety. A WHO alcohol-based formulation. In: WHO guidelines on hand hygiene in health care (advanced draft). Geneva, WHO; 2006 (WHO/EIP/SPO/QPS/05.2; http://www.who.int/patientsafety/en/). World Health Organization/International Labour Organization. Post-exposure prophylaxis to prevent HIV infection: Joint WHO/ILO guidelines on post-exposure prophylaxis (PEP) to prevent HIV infection. World Health Organization, Geneva; 2007. Prevention of Infection Chapter 8-21
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Manual for Male Circumcision under Local Anaesthesia

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