Harbor:Non-Occupational Exposure: Difference between revisions

Revision as of 21:07, 2 March 2020

General Guidelines

Stats on Risk: https://www.wikem.org/wiki/HIV_post-exposure_prophylaxis
CDC Information: http://stacks.cdc.gov/view/cdc/38856.

Harbor ED Policy

Harbor Sexual Assault algorithm and resources: Harbor:Sexual assault
- Harbor - Detailed "How to" for SART Team: https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
  - Preserve all evidence (skin, urine, clothing) and protect chain of custody; address any life-threatening emergencies as appropriate!
  - Limit detailed documentation of described events to avoid future discrepancies
  - Closest SART Center is in San Pedro
  - Forensic Nurse Specialist (SART Staff) available 24/7 at (562) 497-0147
- LA County Public Health HIV PEP Recommendations: https://www.wikem.org/wiki/File:SART_-_Public_Health_HIV_PEP.pdf
  - High-risk HIV exposure: sharing needles with a known HIV-positive partner or a partner of unknown status or unprotected (or failed condom) vaginal intercourse or anal sex
- Los Angeles SART Centers: https://www.wikem.org/wiki/File:SART_Centers.pdf

- OLD Resource https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Sexual%20Assault%20Protocol.pdf
  - High risk exposure (partner or assailant in the case of sexual assault has unknown HIV status, is known HIV+ or highly likely to be HIV+ with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma), occurring within the prior 72 hours. Sexual assault victims should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI prophylaxis and Plan B contraception. If the patient meets these criteria, then first dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's few doses to go home with to tie them over until they can get the 28d course needed from a PEP center.
  - For the vast majority of cases in which a patient seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center. The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure. Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).
  - If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional renal function needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV or infectious disease team at your site, or the National Clinical Consultations Center’s PEPline at (888) 448-4911

References

Authors:

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 ** OLD Resource  https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Sexual%20Assault%20Protocol.pdf
-***Pre-exposure prophylaxis to sexual exposure has been studied as part of a preventive public health strategy and is effective in some well-controlled, very limited circumstances.  This is rarely an emergency medicine issue.
+***High risk exposure (partner or assailant in the case of sexual assault has unknown HIV status, is known HIV+ or highly likely to be HIV+ with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma), occurring within the prior 72 hours.  Sexual assault victims should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI prophylaxis and Plan B contraception. If the patient meets these criteria, then first dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's few doses to go home with to tie them over until they can get the 28d course needed from a PEP center.
-***The possible exception would be the case of exceptionally high risk exposure (partner or assailant in the case of sexual assault is known or highly likely to be HIV positive with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma), occurring within the prior 72 hours.  Sexual assault victims should be referred immediately to a RAPE center where PEP may be offered as part of the overall care plan.
+***For the vast majority of cases in which a patient seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center.  The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure.  Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).
-***For the vast majority of cases in which a patient seeks post-sexual-exposure HIV prophylaxis, the patient should simply be referred to the Los Angeles LGBT Center.  The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure.  Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).  The emergency department is generally not the place to start post-sexual-exposure prophylaxis because it ideally is part of an ongoing risk reduction strategy.
+***If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional renal function needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV or infectious disease team at your site, or the National Clinical Consultations Center’s PEPline at (888) 448-4911
-***If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected.  If the baseline rapid HIV test is negative and if the end of the 72 hour window is near, or it is a Friday night or a weekend, then the HIV service may be consulted, as they may choose to offer a few doses of post-exposure prophylaxis for the patient to take prior to being seen at the LA LGBT Center. Please remember that the HIV fellows and attendings are on call for weeks at a time, so middle of the night calls should be reserved for emergencies.<ref>Email from Dr. Lewis on 1/23/18</ref>
 ==See Also==