Post-exposure prophylaxis (PEP) is a short course of antiretroviral (ARV) drugs taken after a potential exposure to HIV to reduce the chances of becoming infected. This is for situations where HIV transmission might have occurred through occupational incidents or non-occupational events.

Types of Exposure:

• Occupational Exposures: These happen mainly in healthcare or lab environments. Examples include injuries from needles or splashes of body fluids.

• Non-occupational Exposures: These include situations like unprotected sexual contact, sexual assault (e.g., rape), and accidental exposures.

Steps for Providing PEP:

Step 1: Immediate Assessment and First Aid

• Quickly evaluate the person to understand the type of exposure and the level of risk. Provide immediate first aid.

  • For Needle Sticks: Do not squeeze the wound. Wash the area right away with a mild disinfectant. Avoid harsh antiseptics.

  • For Body Fluid on Skin: Immediately wash the affected skin area with a mild disinfectant.

Step 2: Determine PEP Eligibility

• PEP is considered if the exposure happened within the last 72 hours and the person exposed is confirmed to be HIV-negative.

• PEP is not recommended if:

  • The person is already HIV-positive.

  • The source of exposure is known to be HIV-negative.

  • The exposure is from body fluids that are considered to have very low or no risk of HIV transmission (like tears or sweat).

Step 3: Counseling and Support

• Offer comprehensive counseling that covers:

  • The risks of HIV infection.

  • The benefits and possible side effects of PEP medication.

  • The importance of taking PEP medication as prescribed (adherence).

  • Support resources available, especially crucial in cases of sexual assault, offering pathways to further assistance.

Step 4: Prescribing PEP Medication

• PEP should be started as soon as possible after exposure, and ideally within 72 hours for it to be effective.

• Recommended PEP drug combinations:

  • For Adults (including pregnant women): Tenofovir (TDF) + Lamivudine (3TC) + Atazanavir boosted with Ritonavir (ATV/r).

  • For Children: Abacavir (ABC) + Lamivudine (3TC) + Lopinavir boosted with Ritonavir (LPV/r).

• The full PEP course lasts for 28 days.

• Do not delay starting PEP even if baseline HIV test results are not immediately available. Begin PEP promptly.

• Document the exposure incident and how the patient is managed in a confidential PEP register, ensuring patient privacy.

Step 5: Follow-up Care

• Stop PEP after 28 days.

• Schedule an HIV test three months after the exposure to confirm HIV status.

• If HIV-positive: Counsel the individual and link them to an HIV clinic for ongoing care and treatment.

• If HIV-negative: Provide counseling on HIV prevention methods and risk reduction strategies.

ORAL PRE-EXPOSURE PROPHYLAXIS (PrEP)

Pre-Exposure Prophylaxis (PrEP) involves HIV-negative individuals taking antiretroviral (ARV) medication to significantly lower their risk of getting HIV if exposed.

Where is PrEP Available?

Initially, PrEP services are offered at selected, accredited HIV treatment (ART) centers that have the resources and funding for comprehensive PrEP delivery. Expansion to more locations will depend on the results and impact of these initial programs. PrEP is not yet universally available in all public healthcare facilities.

The Process of Providing PrEP:

Step 1: Determine PrEP Suitability

• PrEP is appropriate for HIV-negative individuals at substantial risk of HIV infection. This includes people who:

  • Have multiple sexual partners.

  • Engage in sex for money or goods (transactional sex).

  • Inject drugs or misuse alcohol.

  • Have had multiple sexually transmitted infections (STIs).

  • Are in a relationship where one partner is HIV-positive and the other is HIV-negative (discordant couples).

  • Are repeat users of PEP.

  • Engage in anal sex.

Step 2: Screening for PrEP Eligibility

• For individuals meeting risk criteria, the following screenings are necessary:

  • Confirm HIV-negative status: Essential to ensure PrEP is used by those not already infected.

  • Rule out acute HIV infection: To ensure that early HIV infection is not missed, as PrEP is not treatment for existing HIV.

  • Assess Hepatitis B status:

    • If Hepatitis B negative, the person is eligible for PrEP.

    • If Hepatitis B positive, it requires appropriate medical management and monitoring.

  • Assess for contraindications to Tenofovir/Emtricitabine (TDF/FTC): Check for any health conditions that might make TDF/FTC unsafe for the individual.

Step 3: Starting PrEP

• Provide Risk-Reduction and Adherence Counseling:

  • Give condoms and educate on their correct and consistent use.

  • Work with the individual to create a plan for consistently taking PrEP medication (medication adherence plan).

  • Prescribe a daily pill containing Tenofovir (TDF 300mg) and Emtricitabine (FTC 200mg) to be taken once a day.

  • Initially, provide a prescription for a 1-month supply of TDF/FTC and schedule a follow-up appointment in one month.

  • Counsel the person about potential side effects of TDF/FTC.

Follow-up and Monitoring for PrEP Users:

• Schedule a follow-up visit two months after the initial visit, and then continue with quarterly follow-up appointments.

• Conduct HIV antibody tests every three months to ensure ongoing HIV-negative status.

• Perform pregnancy tests for women as needed, based on their clinical history and potential risk of pregnancy.

• At each visit, review the individual’s understanding of PrEP, identify any challenges to adherence, assess for medication tolerance and any side effects.

• Evaluate and support PrEP adherence at every follow-up appointment.

• Assess for symptoms of STIs and provide treatment as needed.

Guidance on Stopping PrEP:

PrEP may be discontinued under certain circumstances:

• HIV infection occurs: If a person becomes HIV-positive, PrEP is no longer for prevention and they need HIV treatment.

• Reduced HIV Risk: If lifestyle changes significantly decrease the risk of HIV exposure.

• Intolerable Side Effects: If severe or unmanageable side effects from PrEP medication occur.

• Persistent Non-Adherence: If a person consistently struggles to take PrEP as prescribed despite support efforts.

• Personal Choice: If an individual decides to stop PrEP for personal reasons.

• In Sero-discordant Relationships with Viral Suppression: If the HIV-positive partner achieves and maintains viral suppression through treatment (it’s still recommended to consistently use condoms).

MOTHER-TO-CHILD TRANSMISSION OF HIV (MTCT)

Approximately one-third of HIV-positive women, without interventions, can transmit HIV to their children.

Key Elements for Eliminating Mother-to-Child Transmission (eMTCT):

• Prong 1: Primary Prevention for Women and Men: Prevent new HIV infections in women and men of reproductive age, including adolescents, through comprehensive prevention strategies.

• Prong 2: Prevent Unintended Pregnancies in HIV-positive Women: Ensure access to family planning services for women living with HIV, including adolescents, to prevent unintended pregnancies.

• Prong 3: Prevent HIV Transmission from Mother to Child: Prevent HIV transmission from HIV-positive women to their infants during pregnancy, childbirth, and breastfeeding, including adolescent mothers.

• Prong 4: Treatment, Care, and Support: Provide comprehensive treatment, care, and support for HIV-positive women, their children, and families, including psychosocial and medical support.

Timing of HIV Transmission from Mother to Child:

• During Pregnancy: 15-20% of transmissions occur during pregnancy.

• During Labor and Delivery: The majority of transmissions, 60-70%, happen during the birth process.

• After Delivery through Breastfeeding: 15-20% of transmissions can occur through breastfeeding.

Factors Increasing MTCT Risk:

• High Maternal Viral Load: A higher level of HIV in the mother’s blood increases transmission risk.

• Weakened Maternal Immunity: A compromised immune system in the mother (e.g., very low CD4 count) increases risk.

• Prolonged Rupture of Membranes: When the amniotic sac breaks long before delivery, it increases risk.

• Bleeding During Labor: Intrapartum hemorrhage and invasive obstetric procedures increase the baby’s exposure to maternal blood.

• First Twin in Twin Pregnancies: The first twin born often faces a higher risk compared to the second.

• Premature Birth: Babies born prematurely are at higher risk than those born at full term.

• Mixed Feeding: Combining breastfeeding with formula or other foods (mixed feeding) is riskier than exclusive breastfeeding or exclusive formula feeding.

Investigations for MTCT:

• Maternal Blood Test: HIV serological test to determine the mother’s HIV status.

• Infant HIV DNA PCR Testing: Polymerase Chain Reaction (PCR) test to detect HIV DNA in babies.

Management of MTCT:

• All HIV services for pregnant women are integrated into antenatal care (ANC) at Maternal and Child Health (MCH) clinics. After birth, mother and baby remain in the MCH postnatal clinic until the baby’s HIV status is confirmed, then transferred to general ART clinic if needed.

• Current policy aims for elimination of MTCT (eMTCT) through a continuous care approach.

Management of HIV-Positive Pregnant Mothers:

Key Interventions for eMTCT:

• Routine HIV Counseling and Testing in ANC: Offer HIV testing at the first antenatal visit. If initially negative, repeat testing in the third trimester or during labor.

• Enrollment in HIV Care: If the mother tests positive and is not already on HIV treatment, enroll her in HIV care immediately.

• Viral Load Assessment (if on ART): For mothers already on ART, check viral load and continue their current effective regimen.

• Lifelong ART (Option B+): Start and continue Antiretroviral Therapy (ART) for life, initiated as Option B+.

  • Recommended Option B+ Regimen: A single daily Fixed Dose Combination (FDC) pill containing Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV). Start this regimen early in pregnancy regardless of CD4 count and continue throughout pregnancy, labor, delivery, postpartum, and for life.

  • Alternative Regimens (if needed):

    • If TDF is contraindicated (not suitable): Abacavir (ABC) + Lamivudine (3TC) + Efavirenz (EFV).

    • If EFV is contraindicated: Tenofovir (TDF) + Lamivudine (3TC) + Atazanavir boosted with Ritonavir (ATV/r).

  • TDF and EFV are considered safe for use during pregnancy.

  • Women diagnosed with HIV during labor will start lifelong HAART (Highly Active Antiretroviral Therapy) after delivery.

• Prophylaxis for Opportunistic Infections:

  • Cotrimoxazole Prophylaxis: Prescribe Cotrimoxazole 960 mg (1 tablet daily) during pregnancy and postpartum. Mothers on cotrimoxazole prophylaxis do not need Intermittent Preventive Treatment in pregnancy with Sulfadoxine-Pyrimethamine (IPTp with SP) for malaria prevention.

Care of HIV-Exposed Infants:

• HIV-exposed infants should receive care alongside their mothers at mother-baby care points until 18 months of age.

• Goals of HIV-Exposed Infant Care:

  • Prevent HIV infection in the infant.

  • For infants who do become infected, ensure early diagnosis and treatment.

  • Provide child survival interventions to prevent deaths from common childhood illnesses.

• Clinic Visits: The HIV-exposed infant and mother should attend health facility visits at least nine times within the first 18 months (at 6, 10, and 14 weeks, then at 5, 6, 9, 12, 15, and 18 months).

• Nevirapine (NVP) Prophylaxis:

  • Give Nevirapine syrup from birth for 6 weeks to all HIV-exposed infants.

  • Give NVP for 12 weeks for babies at higher risk, specifically breastfeeding infants whose mothers:

    • Started ART within 4 weeks before delivery.

    • Had a viral load >1000 copies/mL within 4 weeks before delivery.

    • Were diagnosed with HIV in the 3rd trimester or during breastfeeding (postnatally).

  • HIV Testing:

    • Perform an HIV PCR test at 6 weeks of age (or at the first encounter after 6 weeks). Start cotrimoxazole prophylaxis at this time.

    • If PCR is positive: Start ART treatment for the infant along with cotrimoxazole prophylaxis. Repeat PCR for confirmation of HIV status.

    • If PCR is negative and the baby has never been breastfed: The child is confirmed HIV-negative. Stop cotrimoxazole prophylaxis, continue routine clinical monitoring, and perform an HIV serology test at 18 months.

    • If PCR is negative but the baby has breastfed/is breastfeeding: Start or continue cotrimoxazole prophylaxis and repeat PCR 6 weeks after breastfeeding is completely stopped.

    • Symptomatic Infants: Follow up any exposed child and perform PCR if they develop any clinical symptoms suggestive of HIV at any point, regardless of previous negative test results.

    • Final HIV Test: For infants who remain negative, perform an HIV serology test at 18 months before final discharge from follow-up care.

• Nevirapine Dosage Guidelines:

  Age Group	Weight Range	Dosage	Syrup Volume (10 mg/ml)
  Child 0-6 weeks	2-2.5 Kg	10 mg once daily	1 ml
  Child 0-6 weeks	>2.5 Kg	15 mg once daily	1.5 ml
  Child 6-12 weeks	Any weight	20 mg once daily	2 ml

• Cotrimoxazole Prophylaxis for Infants: Provide cotrimoxazole prophylaxis to all HIV-exposed infants starting at 6 weeks of age and continuing until HIV infection is definitively ruled out.

  • Child <5 kg: 120 mg once daily.

  • Child 5-14.9 kg: 240 mg once daily.

• Isoniazid Preventive Therapy (IPT): Administer Isoniazid (INH) for six months to HIV-exposed infants who are also exposed to Tuberculosis (TB).

  • Dosage: Isoniazid 10 mg/kg + pyridoxine 25 mg daily.

  • For newborns of mothers with TB who have been on anti-TB drugs for at least two weeks before delivery, INH prophylaxis for the infant is not required.

• Immunization: Vaccinate HIV-exposed children according to the national immunization schedule.

  • If BCG vaccine was missed at birth, do not administer if the child shows symptoms of HIV infection.

  • Avoid Yellow Fever vaccine in children with symptomatic HIV.

  • Measles vaccine is safe and can be given even to children with symptomatic HIV.

• Counseling on Infant Feeding Choices:

  • Clearly explain both the risks of HIV transmission through breastfeeding (estimated at 15%) and the risks associated with not breastfeeding (such as malnutrition and diarrhea).

  • Emphasize that mixed feeding practices can increase the risk of both HIV transmission and diarrhea.

  • Discuss all available infant feeding options, including their advantages and disadvantages.

  • Support the mother in evaluating her choices and deciding on the best feeding option for her and her baby, and then provide support for her chosen method.

• Infant Feeding Options:

  • Recommended Option: Exclusive breastfeeding for the first 6 months, followed by the introduction of complementary foods while continuing breastfeeding.

  • Exclusive Breastfeeding with Early Cessation: Exclusive breastfeeding for a shorter duration (3-6 months) if safe replacement feeding becomes possible after this period. If replacement feeding is adopted early, breastfeeding must be completely stopped.

  • Replacement Feeding: Using home-prepared formula or commercial infant formula, followed by family foods, provided that this method is acceptable, feasible, safe, sustainable, and affordable (AFASS criteria).

• If Mother Chooses Breastfeeding:

  • Advise on practices to keep breasts healthy, as conditions like mastitis and cracked nipples can increase HIV transmission risk.

  • Recommend exclusive breastfeeding for 3-6 months.

• If Mother Chooses Replacement Feeding:

  • Provide thorough counseling and training on safe preparation of formula, hygiene practices, correct amounts, and feeding schedules.

  • Schedule a follow-up visit within a week after birth and at every subsequent health facility visit to monitor and support the chosen feeding method.