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Preventing AIDS After Exposure
by Meenakshi Joshi, BAMS, PG PPHC, PGCPK
Editor's Note: I would like to wish our all of our readers a very happy new year. Here I am posting very useful information about AIDS for health professionals as well as the general public. This is one of the least talked about subjects but a very, very important topic as many of our doctors don't clearly know what action to take. Aids or autoimmune deficiency syndrome is one of the deadliest problems of the century. Many organizations and funds are available to spread awareness about the mode of spread and how to safe guard ourselves from the virus. But very few people have the exact guidelines of what to do if there is an accidental exposure from the virus. Particularly health professionals are at high risk of accidental needle pricks or coming in contact with infectious body fluids. What to do in that situation? Time is the treatment here. Every second is very important post exposure. Few of the medicines taken in emergency can save life. As many of our readers are related to health fields directly or indirectly, I hope this article will give every one enough understanding of PEP or post exposure prophylaxis till the person is shifted to the nearest ART centre.
Many of you might know of my intention behind writing this note at a very short notice. I was just shocked to see that we are not aware of what to do in case of accidental needle prick from an HIV infected source.
I will try to give all details at my level best so that in future this type of situation could not arise. PEP or [ post exposure prophylaxis] is term used for prophylaxis to prevent hospital staff or any one else after any kind of exposure from HIV infected source. The post exposure prophylaxis to HIV is the only way to reduce risk of development of HIV infection after any exposure.
It is a short term antiretroviral treatment that reduces the risk of HIV after exposure. It has to be given in case of any occupational hazard like needle pricks and non occupational like sexual violence.
But in no situation it should be used as a morning after pill and precautions should be taken to prevent the risks and emphasis on the PEP should be judicial.
IN CONTROLLED study it has been found to prevent HIV but incidence of failure has also been recorded.
Mode of Transmission
Transmission can spread from body fluids i.e blood and CSF and through mucosa. It can spread through mucosa and percutaneous but incidence is low. Let me tell you that with needle pricks which are generally percutaneus, the chances of infection found is 0.3 percent from HIV, 30 percent Hepatitis B/HBV and 13 percent from hepatitis C/HCV with single exposure.
Risk Assessment Factors
Time lag between exposure and consultation.
Please remember this is the most significant part of prevention. In every hospital the emergency dept single dose of ART is generally available. It should be consumed within an hour of exposure and send the person to the ART centre for further evaluation.
I am discussing rest of these for awareness purpose. Otherwise the team at ART centre is better equipped to handle and decide if PEP should be started or not.
1. Nature of exposure if skin cut mucosal or percutaneous.
2. Type of contact
3. Severity of the injury
And protective measures after exposure which includes PEP.
These will be considered as High risk factors:
* Injury with instrument visibly contaminated with infected blood
* Pricking of needle giving direct entry in vein or artery
* Deep injury
* Exposure to an AIDS patient having high virus load [stage of patient can be ascertained by judging if he is full blown AIDS or not] or heavy CD4 count
All these factors will help in deciding if further treatment is required or not. Counselling and psychological support is very important. All potential risks of infection may get symptoms like fever skin rash sore throat swollen glands or some times not specific symptoms like fever and headache only. There can be a delay in presenting symptoms, too.
Pathologically there is time lag in between HIV exposure. It goes like viral seeding, replication and infection. Antiretroviral therapy can help in stopping this chain.
Success of PEP is highly dependable on its early initiation.
PEP has shown ineffective results in animal study after 72 hours.
Never the less there is no full proof success.
I want to discuss it here as I have written it should not be used by habitual risk takers as a morning after pill. The therapy has severe side effects and more than 30 percent of the individuals left the therapy in between because of intolerance. So precaution is the only best way to prevent. Most of the side effects are malaise, diarrhoea, nausea and impaired vital functions.
The PEP Therapy Generally in Use
Though zidovudine has been the most effective but combination therapy is best provided. PEP success is in time only… the earlier we start the better risk we are neutralising. Many countries practice two drug therapy and in some three drug. According to new guidelines provided by WHO, it is three drug for high risk exposure and two for low risk. So in an emergency we need to keep just zidovudine and 3TC for first immediate dose and redirect the case for better handling at ART centre.
Let Me Sum Up Again
Try to find out nature and degree of exposure, HIV status of the source. And start PEP if any factor shows risk of infection. Give the basic first dose AZT and 3TC can be offered within an hour after washing the site with soap water. At the ART centre utilize after counselling or finding the source of infection until we may stop further PEP therapy. Otherwise we shift to three drug regime which is more suitable and continue for at least four weeks.
Now the course of action will be to test for HIV anti body at zero, three, six and 12 months. CBD, R/LFT, (aamylase,CPK, sugar at zero, two, four weeks and at three to six months) is required to monitor drug tolerance as I earlier stated. Warning against any seroconeversion illness.
If after all of this, the HIV positive result is shown it has to be referred for HIV management. If PEP was not indicated and stopped after counselling and emergency dose. Here the course of action will be: HIV antibody at zero, three, six months. Warn against any seroconversion illness any time in between. If nothing happens... case can be closed.
Follow up HIV antibody test shall be performed at six months. A test earlier than this can be done at the third month too. And an additional 12 month testing is considered for high risk PEP group to check possibility of late seroconversion. HIV antibody testing and HIV RNA testing can be done for suspected seroconversion cases.
Lastly don’t forget to rule out HBV and HCV. Vaccines are readily available to prevent all this.
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About the Author
Dr. Meenakshi Joshi's expertise is in dealing with stress and life-style challenges. She has practiced herbal medicine, panchkarma, kasharsutra and keraliya therapies for the past fifteen years. She diagnoses through pulse, marma points and prakruti. She is also a trained aroma oil consultant from the FFDC (Fragrance and Flavors Development Centre) and the RTC (Regional Testing Center) from the government of India. She is developing aroma oils and health food supplements for international market.
Dr. Joshi has a post graduate in promotive and preventive health care from Apollo Hospitals as well as panchkarma and ksharsutra from the Manipal Academy of Higher Education. She also has her mandatory BAMS degree in Ayurvedic medicine and surgery.
In terms of writings and presentations, she has presented papers on Ayurveda in seminars at Okayama Medical College in Japan, Middlesex University in the UK and at various other national/international forums. Her inputs are regular in one of the most prominent newspapers in India, the Hindustan Times. She also writes articles for magazines and will soon publish a hand book on basic Ayurveda in two languages.
Visit her website: www.vedichealers.com
Visit her blog: http://drmeenakshijoshi.blogspot.com
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New Delhi, India