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PEP in resource poor setting
Apr 23, 2007

Hello there,

I work for an NGO in South Sudan, where we have only the most basic of clinics and usually no labs. We offer a PEP starter kit to our expat staff who can then be med-evaced out (under insurance cover) for full/specialized care and/or additional ARV in a high-risk situation.

We are planning to offer PEP to our local staff, as well, but we are currently only going to give them Combivir for one month. We will supply our sites with HIV rapid test kits for testing the exposed and the source when possible. Other than that, we will only monitor the person taking PEP clinically. No lab work will be done unless available locally (not much unfortunately).

QUESTIONS: 1. For our expat plan, if a high-risk PEP is recommended, is it okay to wait to start the third ARV until they reach the med-evac location? Or, should we consider having some of that drug (our local insurance cover offers Sustiva or Indivir) in the field so it can be started asap?

2. For our locals, even if we can't give them the high-risk regimen, will the combivir still help if a high-risk exposure occurs? Could it have any bad effect?

3. Locals, is it medically very risky to offer Combivir without doing the lab monitoring? We were looking at it as a 'recommended' but not required thing. Also, we consdired that Combivir has relatively few side effects compared to other drugs.

4. If you have anything documented to support giving Combivir w/o lab tests as a medically 'okay' though not ideal thing, please point me in the right direction. We were not previously offering PEP to local staff and I want to avoid any bureaucratic hurdles if possible!

Many thanks for your assistance!

Response from Dr. Frascino

Hello,

Providing HIV care in a resource-poor setting is extremely challenging, but also critically important. Ideally it would be helpful to have laboratory tests and HIV specialist physicians available when providing and monitoring PEP. However, I fully realize that is not always possible. To specifically address your questions:

1. I don't know how long it takes for someone to reach the med-evac location, but in general I would suggest that beginning Combivir immediately would be the wisest and safest course of action. A third drug can be added to the regimen if needed within the next one or two days following exposure.

2. Yes, Combivir should help in the majority of cases. Adverse side effects and drug-related toxicities can be seen with all antiretroviral drugs. For Combivir, the biggest problem would be AZT-induced anemia.

3. There is some degree of risk associated with all the antiretroviral drugs. It would be important to determine the PEP risk-benefit ratio for each potential HIV exposure.

4. Although not specific for resource-poor settings, I would recommend you review the "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis," which can be downloaded from the U.S. Department of Health and Human Services and Centers for Disease Control Web sites. It was also published in MMWR (Morbidity and Mortality Weekly Report), September 30, 2005 / 54(RR09);1-17.

Good luck!

Dr. Bob



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