Chemoprophylaxis of HIV/AIDS - Park's SPM

1. Post-Exposure Prophylaxis (PEP)

• First aid care
• Counselling and risk assessment
• HIV testing and counselling
• Short-term (28 days) provision of antiretroviral drugs, with support and follow-up

Eligibility for PEP

1. PEP should be offered and initiated as early as possible - ideally within 72 hours of exposure - to all individuals with exposure that has potential for HIV transmission.
2. Assessment for eligibility should be based on the HIV status of the source whenever possible.
3. Exposures that may warrant PEP include:
   • Parenteral or mucous membrane exposure (sexual exposure, splashes to eye, nose, or oral cavity)
   • Bodily fluids posing risk: blood, blood-stained saliva, breast milk, genital secretions, CSF, amniotic, rectal, peritoneal, synovial, pericardial, or pleural fluids
4. Exposures that do NOT require PEP:
   • When the exposed individual is already HIV positive
   • When the source is established to be HIV negative
   • Exposure to: tears, non-blood-stained saliva, urine, and sweat

Assessment of the HIV status of the exposed individual should not be a barrier to initiating PEP. In emergency situations where HIV testing is unavailable but HIV risk is high, PEP should be initiated and testing undertaken as soon as possible.

PEP Regimen

Raltegravir (RAL) 400 mg PO twice daily + Tenofovir DF (TDF) 300 mg / Emtricitabine (FTC) 200 mg (Truvada) 1 tablet PO once daily

Either Raltegravir (RAL) 400 mg BD or Dolutegravir (DTG) 50 mg OD + TDF 300 mg + FTC 200 mg daily

• Dolutegravir is a reasonable once-daily alternative to raltegravir
• 2-drug regimen may be used in special circumstances (unavailability of recommended ARVs, adherence concerns, toxicity) - an expert should be consulted

• All women of childbearing potential must undergo pregnancy testing before initiating PEP
• Non-pregnant women prescribed DTG should use effective contraception during the PEP course
• Pregnant women exposed to DTG should be monitored for neural tube defects (especially if exposure occurred in the first trimester)

2. Co-trimoxazole Prophylaxis for HIV-Related Infections

• Feasible, well tolerated, and inexpensive
• Reduces HIV-related morbidity and mortality in people living with HIV (PLHIV)

WHO Recommendations (2016) - Table 8 of Park's SPM

Adults (including pregnant women)

Infants, Children and Adolescents

• Recommended irrespective of clinical and immune conditions
• Priority: All children < 5 years, regardless of CD4 count or clinical stage
• Also prioritize: WHO stage 3 or 4 and/or CD4 ≤ 350 cells/mm³
• High-prevalence settings (malaria/bacterial infections): continue until adulthood irrespective of ART
• Low-prevalence settings: may discontinue in children ≥ 5 years who are clinically stable / virally suppressed on ART for ≥ 6 months with CD4 > 350 cells/mm³

HIV-Exposed Infants

• Co-trimoxazole prophylaxis recommended from 4-6 weeks of age
• Should be continued until HIV infection is excluded by an age-appropriate HIV test after complete cessation of breastfeeding

HIV-TB Coinfection

• Routine co-trimoxazole prophylaxis should be administered to all HIV-infected people with active TB disease, regardless of CD4 cell count

3. Isoniazid Preventive Therapy (IPT) - for HIV-TB

• Isoniazid Preventive Therapy (IPT) + ART together can reduce the risk of TB among PLHIV by up to 97%.

Summary Table