Episode 42: HIV & Sexual Health Part 2

Author: Eoghan Colgan  @eoghan_colgan
Special Guest: Rebecca Metcalfe @becksmetcalfe

08/01/20

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Guest Bios

Rebecca Metcalfe

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Dr Becky Metcalfe is a Consultant in Sexual Health & HIV Medicine in NHS Greater Glasgow & Clyde. Her special interests include women living with HIV and managing HIV in vulnerable groups. She is part of a team managing an ongoing outbreak of HIV amongst people who inject drugs in Glasgow.

Show Notes

Rebecca Metcalfe is a Consultant in Sexual Health with a specialist interest in HIV, the topic of this episode. Eoghan and Rebecca run through a number of cases and discuss the assessment of risk, what to ask, treatment, advice, follow-up and a whole lot more.

TAKE-HOME POINTS

Post-Exposure Prophylaxis (PEP)

  • a 3-drug combination

    • blue tablet = Tenofovir and Emtricitobine (once a day)

    • red/pink tablet = Raltegravir (twice a day)

  • Studies around PEP are limited, but it has been shown to be effective in some cases

  • Guidelines are to give as soon as possible (and no later than 72 hours)

  • The majority of cases are sexual exposure between men

  • PEP packs are typically 5/7 course (soon to be 7 day in Glasgow) - requires them to have follow-up

    • it is a 28 day course in total

    • don’t give out without doing a baseline HIV test

    • Side-effects - the new combination is tolerated very well (occasional nausea which settles)

      • can impact kidneys so will have U&E’s (plus LFT’s) checked at follow-up

      • very few interactions

      • apart fromm someone with severe renal or liver impairment, there are very few contraindications (in these situations phone for advice)

  • Follow-up before end of discharge pack

    • if sexual expsoure - typically followed-up by sexual health services

    • other exposures typically with Infectious Diseases or Occupational health

  • 5 day follow-up:

    • check U&E’s and LFT’s

    • makes sure the HIV test done in ED is negative

    • check Hep B and Hep C status

  • 28 day follow-up: at end of course to ensure everything ok

  • 8 week follow-up (from exposure) - for HIV antigen-antibody test

    • pretty confident a negative test at this stage is proof not acquired, but will repeat HIV test with Hep C test at 12 weeks from exposure

CASES

  • SEXUAL EXPOSURE

    • A risk-balance analysis

      • working out the chance of acquiring from the episode

      • this can be complex and take some time (so don’t worry too much in ED)

    • In Sexual health Clinic they would ask:

      • who they had sex with

      • what they know about the person they had sex with

        • background?

        • where they met and what they were doing?

        • conversations echanged?

        • are they a friend?

        • do they have sex with men as well as women

        • do they do drugs, and if so what types (do they inject etc)?

        • ethnicity:

          • higher risk in people from Africa

      • type of sex:

        • oral sex = essentially no risk of transmission

        • receptive anal sex = highest transmission

        • vaginal sex is somewhere in between

    • IN ED there are broadly speaking two ‘camps’

      • the ‘definites’

        • the most common is a male receieving anal sex without condom (or condom broken), and nothing known about partner

        • these are straightforward - do HIV test and give PEP, with sexual health follow-up

        • there will also be some definite no’s

      • The ‘considers’: some risky elements to story but not very clear on the total risk

        • ED is not the place to do in-depth risk assessments or calculations so advice would be:

          • if in doubt and any risky elements to story = do HIV test, give PEP and get early follow-up

            • the risks of giving the drug are extremely low

            • it would be worse to underappreciate the risk, and not give the drug, when it should have been given

          • or contact on-call infectious disease person for advice

    • referrals in Glasgow are done by emailing or leaving a telephone message with patinet identifying number (they will contact patient)

    • tests in ED:

      • minimum is HIV test

      • others can be done in clinic, such as: U&E’s, LFT’s, Hep B and Hep C

    • Advice from ED:

      • emphasise the importance of follow-up

      • but also ‘not to worry too much’ - risks are still relatively low

        • you can say: ‘I’m not 100% sure, the drug is fairly safe, and you can go through this in more detail with the specialist’

      • Side effects: practically-speaking it is really just nausea or some mild GI upset

        • typically a short-time period only, but if severe can be managed with antiemetics etc

    • remember to give as early as possible: in clinic they will often give the drug

  • NEEDLE-STICK INJURY

    • History:

      • where it ocurred?

      • what they were doing at the time?

      • When they realised?

      • Did they see the needle?

      • What first aid was done? - encourage bleeding but do not suck the wound!

    • Discussion about risk of acquisition:

      • most people ar quite anxious

      • often difficult to tell risk of infected blood as no knowledge of hhe needles prior use

      • HIV dies quite quickly outside of the body (in air)

        • typically a few hours, but can be longer if not in air

    • IN ED:

      • either phone doctor on-call for Infectious Diseases, or

      • if in doubt: do baseline tests, give PEP, and arrange early follow-up

  • FIGHT-RELATED INCIDENTS

    • similar to others:

      • find out as much as possible about the incident

      • find out as much as possible about the source

        • locations

        • how they met

        • conversations exchanged etc

      • assess the wound

        • spitting incident: no documented transmission

        • splash - also low but depends on the viral load of source (how infected their fluids are)

        • Puncture/bite etc

          • broken skin?

          • depth of wound?

          • any exchange of body fluids and risk of infectivity of source

    • there has been no documented transmission from bites to police/paramedics

    • Management is similar to previous cases:

      • treat high-risk definites

      • everyone else: if in doubt:

        • contact ID on-call, or

        • treat and follow-up early

DETERMINING SOURCE RISK

  • it’s about deciding on the risk that the source person has a BBV

    • Men who have sex with men are much higher risk than heterosexual couples

    • People from Africa

    • an injecting drug user in the centre of glasgow is at much higher risk

    • the appearance of a person cannot be used to determine risk alone

  • testing the source person:

    • can completely include or exclude the risk

    • a sexual partner may be contactable by the sexual clinic

    • hospitals can test the source patients

    • Tests can be done within a couple of hours, but seldom needed that urgently

links

Sandyford Clinic Glasgow: Prep information

https://www.sandyford.org/sexual-health-information/sexual-health/hiv-prevention-testing/prep/

Hannah BellSeP1, SeP2, SeP3, SeP4Comment