postexposure management after sexual violence, prof. hansjakob furrer universitätsklinik für...
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Postexposure management after sexual violence presented by: Prof. Hansjakob Furrer Universitätsklinik für Infektiologie Inselspital Bern at: AIDSFocus Meeting on: 10 April 2014 in: BernTRANSCRIPT
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Prof. Hansjakob FurrerUniversitätsklinik für Infektiologie
Inselspital
Postexposure Management After
Sexual Violence
aidsfocus.ch conference, 10 April 2014, Bern
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23 year old women presents at the emergency department
after a sexual assault, most probably rape
Gyneco Emergency
Lantana
Police
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Content
• Risk of sexually transmitted infections• Course of HIV infection• Measures
– Preemptive treatment– Targeted treatment– Vaccination– Postexposure prophylaxis– Follow-up
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Berner Modell
♀Gyneco
Emergency
♀Medico-
Legal Dpt
♀Dpt Infect Disease
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Source ExposedExposure
Sexual exposure
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Source infectious?
Source ExposedExposure
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Source infectious?
Source ExposedExposition
Sexual exposure
Hepatitis BHIV
Other STDsGonorrhea, Syphilis, Chlamydia
Herpes simplex, Human Papillomavirus, Hepatitis C, ….
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Antimicrobial Treatment
Symptoms
Microbe
Prophylaxis
Preemptive Therapy
Therapy empiric targetedInfection
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23 year old women presents at the emergency department
after a sexual assault, most probably rape Bacterial STD
Syphilis/GO/Chlamydia
Either
Preemptive Therapy at time ofpresentation e.g. Ceftriaxon/Azithromycin
Therapy after diagnosis after ca 14 days (GO,
Chlamydia) Several weeks (Syphilis)
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Source ExposedExposure
Pre-ExposureProphylaxis
Hepatitis B Vaccination
Hepatitis B and HIV
Post-ExposureProphylaxisHIV Drugs
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2-12 weeks 2-14 years 1-6 years
Seroconversion Primary HIV Infection
Asymptomatic
600106
200104
Natural history of HIV-infection
Opportunist. Diseases
AIDSDeath
Plasma HIV RNA (copies/ml)CD4 -Lymphocytes (/µl)Anti-HIV Antibodies
Organ DysfunctionChronic Diseases
Immune-activation
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HIV CycleWeiss, Nature 2001
Inhibitors of the Reverse
TranscriptaseNRTI/NNRTI
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Organ dysfunction
Immune- activationOpportunistic
Infections
Plasma HIV RNA (copies/ml)CD4 -Lymphocytes (/µl)Anti-HIV Antibodies
2-12 Wochen 2-14 Jahre 1-6 Jahre
Primary HIV-infection asymptomatic
600106
200104
Verlauf der HIV-Infektion
Antiretroviral Therapy
Less opportunistic infections
Less organ dysfunction
Longer survival
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HIV-Transmission RiskExposure Risk___________________________________________________Blood Transfusion >90 % /1___________________________________________________Needle exchange 0.7 % /100Receptive anal intercourse 0.5 % (bis 3%)Percutaneous needle stick 0.3 % /1000Receptive vaginal intercourse 0.1 % ___________________________________________________Insertive anal intercourse 0.07 % Insertive vaginal intercourse 0.05 % /10´000Reptive oral intercourse with ejaculation 0.01 %___________________________________________________Insertive oral intercourse 0.005 % /100´000
CDC. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR 2005;54 (no.RR-2): 1-20
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First steps of infection
Hladik et al, Nat Rev Immunol 2008
48-7
2h
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Additional Risk Factors
High HIV- viral load up to >30xViral load undetecable for 3 months virtually no riskOther sexual transmitted infections (GO, HSV, Syph) up to 10xNo Circumcision 2-3xPrimary HIV-infection 10-100x
Rakai-Projekt: Wawer MJ et al. JID 2005;191:4103-9. Gray RH et al. Lancet. 2007. 24;369(9562):657-66
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HIV PCR / HIV-Antibodies (week)
0 1 2 3 4 8 12 16 20 24
Control- / -- / -- / -- / -
- / -- / -- / -- / -
+ / -+ / -+ / -- / -
+ / ++ / ++ / -- / -
+ / ++ / ++ / +- / -
+ / ++ / ++ / +- / -
+ / ++ / ++ / +- / -
+ / ++ / ++ / +- / -
+ / ++ / ++ / +- / -
+ / ++ / ++ / +-/ -
12h- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / --/ -
- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
36h- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / --/ -
72h- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
- / -- / -- / -
- / -- / -+ / +
- / -- / -+ / +
- / -- / -+ / +
Otten RA, J Virology 2000;74(20):9771-5.
Antiretroviral therapy as postexposure prophylaxisDoes it work?
Vaginal exposure in Rhesus Macaques
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Postexposure prophylaxis: as fast as possible!Po
stex
posu
re P
roph
ylax
is
Hladik et al, Nat Rev Immunol 2008
48-7
2h
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23 year old women presents at the emergency department
after a sexual assault, most probably rape
• HBV vaccinated ?– No: vaccination
• Within 48 (72h) after assault– Start immediately with 3 antiretroviral drugs PEP
• 2 NRTIs + Integrase Inhibitor• 3 NRTIs• 2 NRTIs + Protease Inhibitor
– Test aggressor (source)
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HIV Seroconversion, primary HIV infectionLabtests
Klinische Symptome10-20 Tage
Plasma HIV RNAp24-AntigenAnti-HIV Antibodies
Detection limit
10d -12w 5d 5d
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Source infectious?
Source ExposedExposure
Anti-HIV, p24 Ag, (evtl. HIV RNA)
HBsAg, anti-HBc
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Follow-upID
Source ExposedExposure
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23 year old women presents at the emergency department
after a sexual assault, most probably rape
• HBV vaccinated ?– No: vaccination
• Within 48 (72h) after assault– Start immediately with 3 antiretroviral drugs PEP
• 2 NRTIs + Integrase Inhibitor• 3 NRTIs• 2 NRTIs + Protease Inhibitor
– Test aggressor (source)• Stop PEP if HIV-uninfected
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Protection of sex partners (STD, HIV, HBV)
Exposure HBV: If vaccine protected no measures
Exposure HIV: - PEP for 4 weeks- clinical and lab controls- serology for HIV 3 months after end
of PEP
Exposed
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Berner Modell
♀Gyneco
Emergency
♀Medico-
Legal Dpt
♀Dpt Infect Disease