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HIV Prophylaxis Following Non-Occupational Exposure Including Sexual Assault
Updated May 2010 — Currently Under Revision
The New York State Department of Health AIDS Institute (NYSDOH AI) has published guidelines that address HIV post-exposure prophylaxis (PEP) following occupational exposure1 and sexual assault. The purpose of this chapter is to provide recommendations and guidelines for prescribing PEP following non-occupational exposure to HIV including sexual assault. These guidelines will address PEP for significant risk exposures following sexual and needle-sharing activities, needlesticks outside of occupational settings, and trauma, including human bites. Updated guidelines for PEP following sexual assault are also included.
ARV prophylaxis following occupational exposures has been a standard of care for healthcare workers since the 1980s. Prophylaxis following sexual assault has also been recommended in New York State since 1997. Prophylaxis following sexual exposures and other blood exposures, including injection drug use, has been extensively considered and debated. Practice guidelines and policy recommendations for non-occupational HIV prophylaxis must consider the limitations of current scientific knowledge and the lack of definitive evidence concerning efficacy to support such recommendations. Although there are no studies that directly demonstrate the efficacy of non-occupational PEP (nPEP), several data sources support its biologic plausibility, including animal studies of prophylaxis following exposure to simian immunodeficiency virus (SIV) and HIV-2, efficacy data from mother-to-child transmission studies, and case-controlled studies of occupational exposure.2-4 Several studies also support the feasibility of nPEP.5-7
Within the category of sexual exposure, sexual assault merits special focus. Although infrequent, cases of HIV transmission following sexual assault have been described.8,9 As with occupational exposure, exposure occurs at a single point in time and is unlikely to recur. Because of the special considerations regarding evaluation of the risk of HIV exposure as well as counseling and support for sexual assault survivors, PEP in the setting of sexual assault is addressed separately in this chapter (see Section III: PEP for Sexual Assault Survivors).
Developing guidelines for HIV exposures outside of the healthcare setting raises a multitude of issues beyond the questions of biologic rationale and transmission risk. Issues include cost of care, payment for medications, feasibility of implementation of guidelines, individual adherence to nPEP, the risks and benefits of prophylactic ARV therapy, and the potential public health impact of such guidelines. Cost-effectiveness analyses have suggested that nPEP is cost-effective in high-risk exposures such as receptive anal sex with an HIV-infected partner or a partner of unknown HIV status.10,11
Although the most effective way to prevent HIV transmission is to protect against exposure, nPEP offers the possibility of preventing HIV transmission when possible exposure to HIV has occurred. It is likely to be most effective when treatment of high-risk exposures is combined with a strong educational component that emphasizes prevention of future exposures.
The rationale supporting provision of nPEP with respect to the risk of transmission follows a similar logic to that of occupational exposure. Model-based data have indicated probabilities of infection of 0.5% to 3% per episode of receptive anal intercourse12,13 and 0.1% to 0.2% per episode of receptive vaginal intercourse.13,14 The estimated risk for insertive anal and insertive vaginal intercourse, or for oral sex with ejaculation, is lower. The estimated risk of an intravenous needle-sharing exposure is 0.67%.15 The estimated risk from occupational exposure following percutaneous injury is 0.3%.5
Therefore, the per-episode estimated transmission risk for HIV following sexual and injection drug exposures is, in some cases, higher than that for occupational exposure.
In 1998, the Centers for Disease Control and Prevention (CDC) published a commentary on the use of nPEP, which reviewed considerations involved in offering such therapy but did not either recommend or discourage its use.16 Massachusetts and Rhode Island have issued guidelines and procedures for the administration of nPEP, and California has issued guidelines for PEP following sexual assault.17-19 Several countries have official policies regarding nPEP. A number of observational studies have been designed to assess the feasibility and potential efficacy of nPEP programs, including the national HIV Post-Exposure Prophylaxis Registry, which collects information on the use of ARV therapy in non-occupational HIV exposures. Initial published reports from San Francisco, Boston, and Brazil have demonstrated the feasibility of such programs in high-risk populations.6-8
Because there are no randomized, placebo-controlled experimental clinical trials on which to definitively base recommendations, the following NYSDOH guidelines are based on best practice evidence and constitute the considered opinion of the group of expert clinicians in the field of adult HIV medicine who comprise the Medical Care Criteria Committee.
To develop these guidelines for nPEP, the group of clinicians and scientists serving on the Medical Care Criteria Committee reviewed the medical literature as well as existing recommendations and guidelines from government and community sources. They also considered specific concerns related to the process of implementing nPEP. Throughout the discussions of the Committee, a conscious effort was made to weigh both the medical and psychological benefits and risks of medical intervention in the context of a potential HIV exposure.
The Committee addressed the following questions:
- Under what circumstances would individuals at risk for HIV infection benefit from nPEP?
- What settings and program service components allow for the most effective delivery of nPEP?
- What is the appropriate timing for initiation of nPEP? Is there a time after which prophylaxis would not be indicated or advisable?
- Which drugs should be used for nPEP?
- For how long should nPEP be continued?
- What constitutes appropriate monitoring and follow-up?
- What are the cost considerations?
There are many factors to consider when deciding whether to implement nPEP. Figure 1 is meant to serve as a general guide. The sections that follow the figure provide more detail regarding the specific factors that are weighed in decision-making.
II. PEP FOLLOWING NON-OCCUPATIONAL EXPOSURES (nPEP)
This section addresses non-occupational exposures that occur from blood and body fluid exposures, including sexual and needle-sharing activities unrelated to sexual assault. Special considerations for PEP following sexual assault are covered in Section III: PEP for Sexual Assault Survivors. Situations that may prompt a request for nPEP include condom slippage, breakage, or lapse in use by serodiscordant partners; unsafe needle sharing; or other exposure to blood.
A. Assessment to Determine Whether nPEP Is Indicated
Whenever possible, risk assessment and initiation of nPEP should occur in clinical settings where HIV prevention counseling services, as well as HIV clinical expertise, are available or are easily accessed by referral.
Patients who present for nPEP should be evaluated as soon as possible in order to initiate therapy, if indicated, within recommended time frames (see Section IV: Timing of Initiation of PEP for All Non-Occupational Exposures).
When deciding whether to recommend the initiation of nPEP, the clinician should assess and carefully weigh the following factors (see Table 1):
- the behavioral factors and circumstances that led to HIV exposure
- the patient’s risk of HIV acquisition based on the type of exposure
- the possibility that the source is HIV-infected
The clinician should provide risk-reduction counseling and primary prevention counseling whenever someone is assessed for nPEP, regardless of whether PEP is initiated.
Non-occupational PEP should not be prescribed when there is negligible or low risk of HIV transmission (see Table 2).
Non-occupational PEP should not be used as a pre-exposure prophylactic measure to prevent HIV transmission in a woman wishing to become pregnant with an HIV-infected male partner, or as prophylaxis for any person who plans to engage in high-risk behavior.
Clinicians should provide supportive counseling and make referrals for counseling for patients for whom nPEP is not prescribed.
When possible, assessment for and initiation of nPEP should occur in a setting that can provide the following:
- Assessment of HIV risk
- HIV and STD testing and treatment
- Prevention and risk-reduction counseling
- Clinicians with expertise in the use of ARV therapy
- Timely access to care and initiation of nPEP
Clinicians should assess risk, discuss potential risks and benefits of nPEP, provide risk-reduction counseling and education, and provide follow-up care. If patients present with risk exposures at sites that do not offer these services, the clinician should initiate nPEP based on these guidelines, then seek phone consultation with an HIV-experienced provider to review the case. The patient should then be referred to a clinician who has experience in the use of ARV agents and who can provide ongoing prevention counseling for follow-up care. The National Clinicians’ Consultation Center PEP line at 1-888-HIV-4911 (1-888-448-4911) is available for telephone consultation. Patients who present for nPEP should be evaluated as soon as possible by a provider who can perform the assessment outlined in Table 1. In areas where referral is not possible, telephone consultation should be used as part of co-management.
The use of nPEP carries both significant costs and potential risk of toxicity from medications. As a result, it should only be used when the risks of taking nPEP are outweighed by the potential benefits. Non-occupational PEP is not indicated for perceived exposures that are of negligible or low-risk (see Table 2). Prophylaxis during pregnancy attempts by serodiscordant partners is not recommended because other methods of assisted reproduction are presumed to be safer and are preferable for those who can access them. The NYSDOH is currently developing guidelines for assisted reproduction technology in HIV-infected women, which will be posted to www.hivguidelines.org upon completion.
1. Assessing Risk Behavior
Assessment should include a determination of whether the risk is an isolated event, episodic event, or habitual risk behavior. Non-occupational PEP is recommended in situations in which there is an isolated exposure (sexual, needle, or trauma), a lapse in previous risk-reduction practices, or when patients have expressed interest in behavioral change. Situations that may prompt a request for nPEP include condom slippage, breakage, or lapse in use by serodiscordant partners; unsafe needle sharing; or other episodic exposure to blood.
Non-occupational PEP should not be routinely dismissed solely on the basis of repeated risk behavior or repeat presentation for nPEP. Persons who present with repeated high-risk behavior or for repeat courses of nPEP should be the focus of intensified education and prevention interventions. Intent to change behavior should be assessed, and an individualized risk-reduction plan should be developed. Clinicians providing nPEP in the case of repeated high-risk behaviors, despite behavioral intervention, should consider potential medication toxicity, adherence, potential resistance, and cost considerations when determining whether repeat courses of nPEP should be offered. The cost and potential toxicity would outweigh the benefit of nPEP for use in patients who plan to continue to engage in high-risk behaviors and who rely on nPEP as the sole intervention for HIV prevention.
2. Degree of Transmission Risk Based on Type of Exposure
Determining the degree of risk of HIV transmission is an important factor in guiding the patient and clinician in making a decision concerning nPEP. Table 2 lists types of exposures that do not warrant nPEP and those that should prompt consideration of nPEP.
HIV Exposure Through Sexual and Drug-Using Activities
The clinician should have a frank discussion with the patient regarding sexual activities, needle sharing, and other drug-using activities that have a potential for exposure to blood and body fluids (see Table 3). For more information, refer to Prevention with Positives: Integrating HIV Prevention into HIV Primary Care.
Risk evaluation should also assess whether factors known to further increase the risk of transmission of HIV infection are present, including trauma at the site of exposure, the presence of genital ulcer disease and/or other STDs, and high plasma viral load in the HIV-infected partner/source. Other factors that may enhance transmission include cervical ectopy and lack of circumcision.
HIV Exposure Through Needlestick Injuries
Another route of exposure that prompts requests for nPEP is needlestick injuries in the non-healthcare setting. Factors associated with risk from needlestick injuries in the non-healthcare setting include the potential source of the needle, type of needle, presence of blood, and skin penetration.
People who incur needlestick injuries from discarded needles are often concerned about potential HIV exposure. Consideration of potential risk from discarded needles should include the prevalence of HIV in the community or facility where the exposure occurred and the surrounding prevalence of injection drug use. Discarded needles should not be tested for HIV because of low yield and the risk of injury to personnel involved in testing. Vaccination to prevent tetanus may be indicated for needlestick injuries resulting in puncture wounds.
HIV Exposure Through Bites
An estimated 250,000 human bites occur annually in the United States in a variety of settings. Although possible, HIV transmission following bites is thought to be extremely rare. While there have been many reported instances of bites, there have been few cases of HIV transmission as a result of a human bite exposure. The few documented cases of possible HIV transmission following bites were in adults exposed to blood-tinged saliva.22,23
A bite wound that results in blood exposure should prompt consideration of nPEP. When a human bite occurs, it is possible for either the person bitten or the biter or both to have incurred blood exposure. Use of nPEP in this setting potentially would be indicated only when there is significant exposure to deep, bloody wounds. Blood exposure could occur in the following scenarios involving bites:
- Blood exposure to the biter: when the biter inflicts a wound that breaks the skin, and blood from the bitten person enters the biter’s mouth
- Blood exposure to the bitten person: when the biter has blood in his/her mouth (e.g., from bleeding gums or lesions) and inflicts a wound that breaks the skin of the person bitten
- Blood exposure to both parties: when there is a break in the skin of the person who was bitten and the biter had blood in his/her mouth (e.g., from bleeding gums or lesions)
A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted.
3. Considering the HIV Status of the Exposure Source
If the source of contact is known to be HIV infected, information about his/her CD4 count, viral load, ARV medication history, and history of ARV drug resistance should be obtained when possible to assist in the selection of an nPEP regimen. If the source is anonymous, or the contact’s HIV status is not known, the source’s potential risk of having HIV infection should be assessed (see Table 4). Regional information regarding HIV prevalence also should be considered.24
B. Baseline Testing for Patients Who Present With Risk Exposures
The clinician should perform baseline HIV testing of the exposed person. Initiation of nPEP should not be delayed pending HIV test results. Where available, rapid testing should be used.
The clinician should perform an assessment for other sexually transmitted diseases, such as chlamydia, gonorrhea, and syphilis, and should provide STD prophylaxis in sexually exposed patients.
The clinician should obtain baseline pregnancy testing for exposed women. Emergency contraception should be offered to and discussed with women at risk of pregnancy from the exposure.
Risk behaviors leading to HIV infection also put the patient at risk for other STDs. Patients who present for nPEP should receive baseline HIV counseling and testing as well as evaluation and prophylaxis for other STDs after a sexual exposure. Rapid HIV testing is the preferred method of HIV testing in this situation because it can immediately identify patients who were already infected with HIV at the time of presentation in order to avoid unnecessary risks from inappropriate initiation of nPEP. When rapid testing is not available, nPEP should be started without waiting for the results of the HIV test, otherwise the 36-hour window of effectiveness for nPEP would be lost. A negative antibody test only demonstrates that the patient was not previously infected with HIV; therefore, nPEP would still be initiated when indicated. Emergency contraception for female patients should be initiated within 72 hours of the sexual exposure to be effective; optimally, pregnancy prophylaxis should be initiated within 12 hours of the exposure. The following websites offer more information about the use of emergency contraception:
C. Deciding to Recommend nPEP
The clinician should initiate nPEP ideally within 2 hours and generally no later than 36 hours following exposure when an isolated exposure (sexual, needle, or trauma) has occurred or when risk-reduction practices fail.
The clinician should discuss the following issues with the patient and should document that they were discussed before initiating a regimen:
- the potential benefit, unproven efficacy, and potential toxicity of nPEP
- the need for adherence
- the need to initiate/resume risk-reduction and preventive behaviors
- signs and symptoms of primary HIV infection
- the need for clinical and laboratory monitoring and follow-up
The patient should agree to follow-up monitoring and initiation of interventions to reduce risk, if applicable, before the clinician initiates nPEP. All components of this discussion should be documented so that events leading to infection can be clearly identified and the efficacy of nPEP can be assessed.
ARV medications have the potential to cause significant side effects and toxicity. The patient should be made aware of these possibilities and weigh them against the potential but unproven benefit of nPEP. Non-occupational PEP is presumed to be more effective when patients strictly adhere to the prescribed regimen. Follow-up visits will need to occur on a regular basis to assess for adherence, drug tolerance, and medication toxicity (see Section VI: Monitoring Following Non-Occupational Exposure Including Sexual Assault).
Sexual assault survivors can access reimbursement through the Crime Victims Board; however, reimbursement for other types of nPEP is not generally available for the uninsured, and private insurers may refuse to reimburse for it. This challenging issue should be discussed during counseling before nPEP is initiated. Strategies should be sought to address this reality.
D. Behavioral Intervention and Risk-Reduction Counseling
Behavioral intervention for risk reduction should occur regardless of whether nPEP is initiated or not.
Clinicians should assess for emotional, psychological, and social factors that can contribute to risk behavior, such as depression, history of sexual abuse, and drug and alcohol use.
Clinicians should refer patients to mental health and/or substance use programs when indicated and should consider the need for intensive risk-reduction counseling services.
Presentation of persons with repeated high-risk behavior or for repeat courses of nPEP should be viewed as an opportunity for intensification of education and prevention planning in a high-risk individual. Intent to change behavior should be assessed, and an individualized risk-reduction plan should be developed. For more information, refer to Prevention with Positives: Integrating HIV Prevention into HIV Primary Care.
III. PEP FOR SEXUAL ASSAULT SURVIVORS
Survivors of sexual assault should be treated in an emergency department or equivalent healthcare setting where all appropriate medical resources are available as needed.
A. Assessment to Determine Whether nPEP Is Indicated Following Sexual Assault
When deciding whether to recommend the initiation of nPEP following sexual assault, the clinician should assess and carefully weigh the following factors:
- whether or not a significant exposure has occurred during the assault
- knowledge of the HIV status of the alleged assailant
- whether the survivor is ready and willing to complete the nPEP regimen
The clinician’s decision to recommend nPEP should not be influenced by the geographic location of the assault.
Although the seroprevalence of HIV in different New York communities may vary, the HIV status of an individual who has been accused of perpetrating a sexual assault remains unknown until that individual has been tested. It is also important to consider that HIV prevalence in sexual assailants may be higher than that in the general population.24 In the acute setting of sexual assault, the decision to recommend prophylaxis should not be based on the geographic location of the assault but rather on the nature of the exposure during the assault, the readiness of the survivor to initiate and adhere to the prophylactic regimen, and the HIV status of the alleged assailant, if known.
1. Degree of Risk Based on Type of Exposure
Clinicians should recommend HIV nPEP to survivors when significant exposure may have occurred, as defined by direct contact of the vagina, anus, or mouth with the semen or blood of the alleged assailant, with or without physical injury, tissue damage, or presence of blood at the site of the assault.
Non-occupational PEP should also be offered in cases when broken skin or mucous membranes of the survivor have been in contact with blood or semen of the alleged assailant. Similarly, nPEP should be offered in cases of bites that result in visible blood.
Genital trauma is present in the majority of sexual assault survivors, with anal trauma present in just over half. Absence of visible trauma does not indicate that an assault did not occur; microabrasions are common and the appearance of manifestations may be delayed. Oral trauma may also occur during sexual assault with potential exposure to blood or semen from the alleged assailant, which would carry a potential risk for HIV exposure. Bites or trauma may be inflicted during an assault and are indications for prophylaxis if there is contact with blood or semen from the alleged assailant.
2. Considering the HIV Status of the Alleged Assailant
Unless the identity and HIV status of the alleged assailant has been clearly established to assist with the decision-making, nPEP should be promptly initiated when a significant risk exposure has occurred.
Even when the alleged assailant is known to be HIV infected, the decision to recommend nPEP should be based on the nature of the exposure and the survivor’s ability to complete the regimen.
If prophylaxis has been initiated and the alleged assailant is found to be HIV antibody negative, then nPEP should be discontinued.
As of November 1, 2007, New York State Criminal Procedure Law § 210.16 requires testing of criminal defendants, indicted for certain felony sex offenses, for human immunodeficiency virus (HIV), upon the request of the victim. For guidance on defendant testing, please visit NYS Court-Ordered HIV Testing of Defendants.
In most instances, the HIV status of the alleged assailant will not be known and cannot be available in sufficient time to influence the decision to initiate nPEP. If the HIV status of the alleged assailant is established and confirmed, ideally through the use of rapid testing, that knowledge should be used in decisions to initiate or continue nPEP, as well as to assist in choosing the PEP regimen if viral resistance data are available. Testing of the source should be pursued in accordance with New York State Public Health Law and Regulations.
It is not possible to know whether an alleged assailant has HIV infection solely on the basis of risk behaviors. Categorical judgments should not be made on the basis of perceived risk. The decision to offer prophylaxis should be based on whether significant exposure has occurred during the assault rather than on the risk behavior of the alleged assailant.
When the survivor knows the alleged assailant personally, assumptions about HIV status or risk should have limited influence on the decision to initiate prophylaxis. Familiarity with the alleged assailant may influence the survivor’s perception of risk, which will influence his/her decision to initiate nPEP. Because HIV risk behaviors and status may be hidden from close friends and family, decisions based on familiarity with the alleged assailant should be made cautiously.
If the alleged assailant has not been confirmed to be HIV antibody negative, then the decision to initiate nPEP should be based on the nature of the exposure and the survivor’s ability to complete the treatment. If the alleged assailant has been confirmed to be HIV antibody positive, HIV-specific information about the source, including a treatment history, should be obtained because it may influence the recommended nPEP regimen. Consultation with a provider with experience with ARV therapy is especially recommended when the source person is known to harbor drug-resistant HIV because an alternate nPEP regimen may be more effective. However, initiation of the first dose of nPEP should not be delayed while awaiting this information.
B. Recommending nPEP for Sexual Assault Survivors
Non-occupational PEP should be initiated as soon as possible after exposure. Non-occupational PEP is unlikely to be effective more than 36 hours post-exposure (see Section IV: Timing of Initiation of PEP).
In New York State, hospitals providing treatment to victims of sexual assault must have seven-day starter packs of medication available on-site for rapid initiation of nPEP following sexual assault. Arrangements should be made to ensure that the patient receives a continued supply of medication and an appointment is made with a clinician experienced in HIV PEP.
The recommendation for nPEP should be communicated simply and clearly to the patient, considering his/her emotional state and ability to comprehend the nature of ARV treatment.
If a sexual assault survivor is too distraught to engage in a discussion about the drug regimen or make a decision about whether to initiate treatment at the initial assessment, the clinician should offer a first dose of medication and make arrangements for a follow-up appointment within 24 hours to further discuss the indications for nPEP.
If a sexual assault survivor decides to initiate treatment, a follow-up visit should be scheduled within 24 hours to review the decision, evaluate initial drug tolerability, reinforce the need for adherence to the regimen, and arrange for follow-up care. In New York State, hospitals providing treatment to victims of sexual assault must provide or arrange for an appointment for medical follow-up related to nPEP and other care as appropriate. See the Voluntary HIV Provider Directory.
The discussion regarding initiation of nPEP should include the following:
- The potential to prevent HIV infection
- Possible side effects of the nPEP regimen
- Duration of nPEP and the monitoring schedule
- Importance of adherence to the treatment regimen to prevent nPEP failure or the development of drug resistance should infection occur
Because evidence indicates the need to begin prophylaxis within hours after an exposure, the clinician is in the position of deciding how strongly to advise the survivor to initiate the regimen. This requires the clinician to balance the survivor’s readiness with the knowledge that the most efficacious intervention should occur promptly. If a patient is too distraught to engage in discussion, he/she should be encouraged to take a single dose of nPEP, and then revisit the issue the following day. The risk of taking one dose is likely to be minimal, and the efficacy that would be lost if delayed a whole day may be salvaged. However, if the victim decides to defer making a decision at the time of the initial intervention, then the follow-up visit to consider nPEP should occur within 24 hours of the exposure to ensure that nPEP is started within 36 hours of exposure. This follow-up visit also offers clinicians a chance to re-evaluate the decision to initiate nPEP. If the survivor is pregnant, a full discussion of the benefits and risks of prophylaxis for both maternal and fetal health should occur (see Section VII: Non-Occupational PEP for the Pregnant Patient).
Various payment methods for nPEP are available for survivors of sexual assault, including Medicaid, Medicare, or Crime Victims Compensation. Third-party reimbursement may cover nPEP, depending on the plan’s prescription drug policy, if the individual has prescription drug coverage. In cases where the medication-dispensing facility does not receive reimbursement for these services, such expenses may be included in their annual Institutional Cost Report as part of indigent care costs. Timely initiation of medication is crucial to the success of nPEP, and hospitals providing treatment to victims of sexual assault are required to have seven-day starter packs available onsite.
The Crime Victim’s Board (CVB) has developed special procedures to ensure availability of nPEP for sexual assault victims. CVB will contact the prescription provider to attempt to facilitate availability of needed drugs, if requested to do so, and will directly reimburse pharmacy providers. Documentation of a visit to a medical facility that provides a forensic physical examination satisfies the CVB reporting requirement, thereby providing access to compensation for people who may be either unwilling or unable to report the crime to the police.
For Crime Victims Compensation, claim forms can usually be obtained from hospital emergency departments and can also be downloaded from the Crime Victims Board website at www.cvb.state.ny.us. Survivors of sexual assault may also contact a Rape Crisis Center or Victims Services Agency in their county or region for assistance in filing claims with CVB, particularly when emergency assistance is needed. Many of these agencies have 24-hour hotlines. For more information about accessing Crime Victims Compensation, and for a list of victims services agencies and other resources, consult the CVB website at www.cvb.state.ny.us.
C. The Role of the Rape Crisis Counselor and Sexual Assault Examiner
The rape crisis counselor should be an active participant in the discussion regarding HIV nPEP.
The plan for follow-up care should be discussed with the rape crisis counselor or an outreach worker who will be working with the survivor following the survivor’s departure from the emergency department or equivalent healthcare setting.
The rape crisis counselor is often a volunteer from the community whose primary role is to provide comfort, assistance, and information to the survivor. The counselor is neither an employee of the healthcare facility nor a representative of the Department of Health. The active role that a counselor plays in the decision-making process to initiate nPEP and to facilitate ongoing care and monitoring depends solely on the decision of the survivor to accept such involvement. To the extent possible, the treating clinician and the rape crisis counselor should coordinate care to encourage medical follow-up and adherence to nPEP. Through this effort, the rape crisis counselor may become the crucial link between the survivor and the provider, clarifying communication and facilitating follow-up care for the survivor. When the survivor does not have a primary care provider or has difficulty arranging access to a provider with experience with HIV PEP, this link becomes especially important. Support from the counselor will increase the likelihood that the individual will adhere to the nPEP regimen and that medical problems will be addressed expeditiously when they arise.
If the rape crisis counselor is part of the multidisciplinary healthcare team as determined by the clinician, then the counselor may provide additional support to the survivor in the test counseling process (see Section D: HIV Testing of the Survivor). If the counselor is not part of the treatment team, permission to communicate HIV-related information to him/her will need to be obtained in writing from the survivor. Specific permission does not need to be obtained to discuss the general benefits and risks of ARV therapy or the decision to initiate nPEP.
The sexual assault forensic examiner (SAFE) also plays a critical role in management of care following sexual assault. Sexual assault forensic examiners are specially trained in areas such as forensic techniques (e.g., screening for the presence of “date rape” drugs) and health care of sexual assault survivors (e.g., emergency contraception, treatment for possible exposure to STIs). See Appendix C for more information about the SAFE programs in New York State.
D. HIV Testing of the Survivor
Clinicians should obtain blood for baseline HIV serologic testing when recommending initiation of nPEP. Prophylaxis, when indicated, should be started without waiting for the results of this test.
Refusal to undergo baseline testing should not preclude initiation of nPEP.
Because a negative antibody test only demonstrates that the patient was not previously infected with HIV, nPEP is still indicated when a risk exposure has occurred. When rapid testing is not available, nPEP should be started without waiting for the results of the HIV test, otherwise the 36-hour window of effectiveness for nPEP would be lost. Rapid testing allows for preliminary identification of previously HIV-infected patients within 30 minutes, so that unnecessary risks from inappropriate initiation of nPEP can be avoided. Possible complications of initiating nPEP without baseline HIV testing in the context of sexual assault include the inability to subsequently establish that the assault resulted in HIV transmission, if the survivor later tests positive for HIV.
If the survivor prefers not to undergo HIV testing in the emergency department setting, a referral should be arranged to obtain HIV testing the next day. If excess blood is remaining from blood specimens obtained in the emergency room for other reasons, it may be used for later HIV testing only if informed consent has been obtained.
The emergency department provider should obtain the HIV test; however, with agreement of all parties, this responsibility may be transferred to the treating clinician or primary care provider. If the survivor is being treated with nPEP, this responsibility should be coordinated with the treating clinician, who may need to discuss long-term treatment options with the survivor should he/she seroconvert. If the survivor is not under the care of a primary care physician or HIV provider, the emergency department provider who has obtained the test is responsible for communicating the result in person to the survivor.
IV. TIMING OF INITIATION OF PEP FOR ALL NON-OCCUPATIONAL EXPOSURES
Non-occupational PEP should be offered as soon as possible after exposure and initiated ideally within 2 hours and generally no later than 36 hours following exposure. Non-occupational PEP is unlikely to be effective more than 36 hours post-exposure.
Animal models of nPEP have shown that effective ARV treatment is most likely to prevent infection when initiated within 24 hours of experimental simian immunodeficiency virus (SIV) exposure. It is unknown whether initiation of nPEP beyond this point confers protection. With the exception of nevirapine, which is immediately active intracellularly, the currently recommended nPEP drugs require an intracellular activation step that delays the onset of antiviral activity. Thus, clinicians should begin nPEP as soon as possible following an exposure that carries a risk of HIV transmission, and generally no later than 36 hours, although an absolute elapsed time after which nPEP should not be given cannot be stated with certainty.
Decisions regarding initiation of nPEP beyond 36 hours post exposure should be made by the clinician in conjunction with the patient with the realization of diminished potential for success when timing of initiation is prolonged. Some individuals who have survived sexual assault or who have higher risk exposures (i.e., unprotected anal receptive intercourse with a known HIV-infected partner) may wish to initiate nPEP, even though they may present for treatment more than 36 hours following the exposure. If the clinician strongly suspects that HIV transmission is likely to have occurred, consultation with a provider with experience with HIV PEP is strongly advised.
Once a decision has been made that nPEP is indicated, patients should be encouraged to initiate the regimen immediately. Supports to facilitate adherence with the treatment regimen should be evaluated and provided to the extent possible.25
V. RECOMMENDED nPEP REGIMENS
Clinicians should initiate three-drug ARV therapy for significant exposures to HIV. The preferred nPEP regimen is shown in Table 5. Alternative agents may be used in the setting of drug intolerance or toxicity (see Table 5 and Appendix A).
Starter packs of medication should be available on-site for rapid initiation of treatment, and arrangements should be made for continuation of treatment.
When the source is known to be HIV infected and information regarding previous ARV therapy, current level of viral suppression, or genotypic/phenotypic resistance profile is available, the clinician, in consultation with a provider with experience with HIV PEP, should individualize the regimen to more effectively suppress viral replication.
The nPEP regimen should be continued for 4 weeks.
Once a decision has been made that a significant risk exposure has occurred and that nPEP is warranted, three-drug combination therapy should be offered unless contraindications exist. This recommendation is identical to NYSDOH guidelines for prophylaxis following occupational exposure. Some occupational and non-occupational PEP programs have used a two-drug regimen due to adherence and cost issues; however, this Committee recommends that all PEP regimens contain a minimum of three ARV agents, which will more likely decrease viral burden. The Committee chose tenofovir as the third agent because it achieves high intracellular levels and has been effective in trials of PEP in primates. The combination of two NRTIs plus tenofovir has high failure rates for treatment of established HIV infection and is only recommended for PEP where the goal is prevention of infection and not treatment.
Timely initiation of medication is crucial to the success of PEP. Starter packs of medication should be available on-site for rapid initiation of treatment, and arrangements should be made for continuation of treatment.
Current guidelines for prophylaxis following occupational exposure recommend treatment for 4 weeks. These same recommendations should apply to PEP following non-occupational exposure. Continuation of treatment beyond 4 weeks will depend on results of HIV serologic testing.
If the patient’s baseline HIV test shows evidence of HIV infection acquired before starting nPEP, then the decision to continue ARV therapy should be based on accepted treatment guidelines and resistance test results, taking into account the patient’s CD4 status and willingness to continue therapy. In the case of an indeterminate test and in the setting of symptoms suggestive of primary HIV infection, the clinician should continue ARV treatment until a definitive diagnosis is established. A provider with experience with ARV therapy should be consulted.
As experience with nPEP continues to accumulate, it has become increasingly clear that the reasons for non-adherence to nPEP are multifactorial. Factors affecting adherence include ARV drug intolerance, regimen complexity, fear, anxiety, expense, frustration, and beliefs that the regimen will not work. Although there are no clinical trial data (other than that with zidovudine), based on post-exposure animal data using tenofovir and its excellent tolerability and simplicity,26 the Committee now recommends the simpler standard nPEP regimen of zidovudine, lamivudine, and tenofovir. Substitutions for tenofovir include the PIs nelfinavir and lopinavir/ritonavir (co-formulated as Kaletra). If these cannot be used, an NNRTI may be considered. In the setting of renal insufficiency, tenofovir and lamivudine may require dose reduction or may be contraindicated (see Appendix A). The package insert for these agents should be consulted.
Reports of nevirapine-induced hepatotoxicity among people receiving PEP have led to the recommendation that nevirapine be considered as an alternative component of the nPEP regimen only when NRTIs and PIs are not an option.27 Use of efavirenz in an nPEP regimen should only be considered in men and in women not capable of bearing children because it has been associated with teratogenicity in animal studies and in humans anecdotally.
VI. MONITORING FOLLOWING NON-OCCUPATIONAL EXPOSURE INCLUDING SEXUAL ASSAULT
Clinicians should closely monitor people receiving nPEP to detect ARV-induced toxicities.
Because of the complexity and potential adverse effects of the nPEP regimens, longitudinal care of the exposed patient should be provided either directly by or in consultation with a provider with experience with HIV PEP.
Sequential confidential HIV testing should be obtained at baseline, 1, 3, and 6 months post-exposure even if nPEP is declined (see Table 6). In New York State, if the test result is positive, a Western blot assay must be performed to confirm the diagnosis of HIV infection.
Any acute febrile illness post-exposure accompanied by one or more of the following—rash, lymphadenopathy, myalgias, sore throat—suggests the possibility of acute HIV seroconversion and requires urgent evaluation. If the patient presents with signs or symptoms of acute HIV seroconversion, immediate consultation with a provider with experience with HIV PEP should be sought for optimal diagnostic testing and treatment options.
Post-exposure care involves simultaneous attention to multiple issues: the emotional state of the exposed patient, adherence to the nPEP regimen, monitoring for potential adverse effects, and sequential HIV testing to exclude acquisition of infection.
Approximately 50% of patients in whom nPEP is initiated do not complete therapy due to side effects or non-adherence. When a patient is potentially exposed to HIV, longitudinal medical follow-up of the patient is necessary regardless of whether nPEP is initiated and/or completed, in order to test sequentially for HIV infection. Follow-up is necessary for patients receiving nPEP to monitor for adverse effects of the nPEP regimen and maximize adherence to the prescribed regimen.
When infection occurs, the ELISA will generally be positive within 3 weeks of the onset of symptoms and is virtually always positive within 3 months following exposure. The confirmatory Western blot may yield an indeterminate result during the early stages of seroconversion. Subsequent testing should be performed to confirm definite seroconversion.
Approximately 50% of patients acutely infected with HIV will experience at least some symptoms of the acute retroviral syndrome. Symptoms may include pharyngitis, morbilliform rash, thrush, lymphadenopathy, and hepatosplenomegaly. Acute HIV infection is often not recognized in the primary care setting because of the similarity of the symptom complex with that of the “flu” or other common illnesses. When acute HIV seroconversion is strongly suspected based on the clinical scenario, a plasma HIV RNA assay should be used in conjunction with an HIV-1 antibody test to diagnose acute or primary HIV infection. See Diagnostic, Monitoring, and Resistance Laboratory Tests for HIV for further information on HIV testing, and Diagnosis and Management of Acute HIV Infection for further information on management of acute HIV infection.
VII. NON-OCCUPATIONAL PEP FOR THE PREGNANT PATIENT
Before administering nPEP to a pregnant woman, the clinician should discuss the potential benefits and risks to her and to the fetus. Drugs to avoid during pregnancy are listed in Table 7.
Based on increasing clinical experience with HAART, nPEP is indicated at any time during pregnancy when a significant exposure has occurred, despite possible risk to the woman and the fetus. Expert consultation should be sought. When nPEP is indicated, it should be initiated within 36 hours of exposure.
Clinicians should not prescribe efavirenz for pregnant women because it has been associated with teratogenicity in monkeys.
Clinicians should not prescribe the combination of didanosine and stavudine due to an increased risk of mitochondrial toxicity in pregnant women.
Unboosted indinavir should not be used in pregnant women in the second or third trimester due to a substantial decrease in antepartum indinavir plasma concentrations.
Clinicians should advise women who may have been exposed to HIV to avoid breastfeeding28 for 6 months after the exposure.
Initiation of nPEP at any time during pregnancy requires a careful discussion of the risks and benefits of this therapy. In addition to the risk of seroconversion for the patient, there is a high risk of transmission to the fetus or breastfeeding infant,28 should the pregnant patient develop the acute retroviral syndrome. Although birth defects and adverse effects on human fetuses have generally not been associated with the currently available ARV agents, exposure of a fetus to ARV agents during pregnancy carries a theoretical risk of teratogenicity.
The recommendation to initiate nPEP in the breastfeeding patient presents several concerns. Both HIV and ARV drugs may be found in breast milk. As such, breastfeeding should be avoided28 for 6 months after the exposure to prevent HIV transmission and potential drug toxicities. Because HIV infection is most often diagnosed within 3 months of exposure, some women may prefer to breastfeed between 3 to 6 months following exposure. Clinicians should discuss the risks and benefits with the patient. The infant’s pediatrician should be informed of any potential exposure to HIV or ARV medications.
For additional information, refer to NYSDOH guidelines on Management of the HIV-Infected Pregnant Woman.
VIII. NON-OCCUPATIONAL PEP FOR HEPATITIS B AND C
Updated May 2010 — Currently Under Revision
When a non-occupational exposure occurs, and the source is available, the source should be evaluated for both hepatitis B and hepatitis C. (AII)
A. Hepatitis B Virus Post-Exposure Management
The hepatitis B vaccine series should be initiated in non-HBV-immune persons who sustain a blood or body fluid exposure. (AI)
Administration of prophylactic hepatitis B immune globulin (HBIG) and the initiation of the hepatitis B vaccine series is recommended when the non-HBV-immune person sustains a blood or body fluid exposure to a source person with known acute or active HBV (see Table 8). (AI) Both HBIG and the first dose of the hepatitis B vaccine series should be ideally administered within 24 hours of exposure (AII); HBIG should not be given later than 14 days post-exposure. The three-dose HBV vaccine series is given at 0, 1 to 2 months, and 6 months.
Needlestick injuries and wounds should be washed with soap and water and should not be squeezed. Mucous membranes should be flushed with water. (AIII)
Initiation of the HBV vaccine series within 12 to 24 hours of an exposure has been demonstrated to be 70% to 90% effective in preventing HBV infection. The combination of vaccine and HBIG achieves a similar level of efficacy. Among known non-responders to vaccination, one dose of HBIG is 70% to 90% effective in preventing HBV when administered within 7 days of percutaneous HBV exposure,29 and multiple doses have been shown to be 75% to 95% effective.30 The maximum effective interval for prophylaxis is likely within 14 days for sexual exposure.31-35 Pregnant women can safely receive both the HBV vaccination and HBIG.
When considering nPEP for HBV exposures, both the source’s HBsAg status and the exposed person’s vaccination status should be considered (see Table 8). Determination of antibody response of previously vaccinated exposed persons should be based on information available at presentation. It is not recommended that decision-making be delayed while testing for anti-HBs. If antibody response is unknown, follow recommendations for “antibody response unknown” in Table 8.
Both HBIG and the first dose of the hepatitis B Vaccine should be ideally administered within 24 hours of exposure; HBIG should not be given later than 14 days post-exposure. The three-dose HBV vaccine series is given at 0, 1 to 2 month, and 6 months. Hepatitis B antibodies should be obtained 1 to 2 months after completion of the third dose of the vaccine; however, levels may be falsely elevated if the exposed person received HBIG within the past 3 to 4 months.
Even if the risk of exposure to HBV is not deemed significant, HBV vaccination should still be advised for all non-HBV-immune persons (see Hepatitis B Virus guidelines for more information). Household, sex, and needle-sharing contacts of HBsAg-positive individuals should be identified and vaccinated according to the guidelines for patients exposed to known HBsAg-positive individuals.
B. Hepatitis C Virus Post-Exposure Management
Clinicians should consider concurrent exposure to HCV when individuals present with an HIV exposure. (AII)
Neither immunoglobulin nor antiviral agents are recommended for HCV post-exposure prophylaxis.
When HCV infection is identified, the exposed person should be referred for medical management to a gastroenterologist or other clinician with experience in treating HCV. (AII)
Currently, no effective prophylaxis for HCV has been identified. Immunoglobulin and antiviral agents are not recommended for HCV post-exposure prophylaxis (PEP). However, if an individual becomes acutely infected with hepatitis C and is diagnosed at that time, immediate referral to a provider experienced in the treatment of hepatitis C is recommended. Recent data suggest that early treatment of acute hepatitis C with interferon is highly effective, perhaps as high as 95%.31
1. Baseline Management
Following an exposure to blood or body fluid, the clinician should assess the risk for exposure to HCV. (AII) Wounds should be washed with soap and water, and should not be squeezed. (AII) Mucous membranes should be flushed with water.
Once the clinician has determined that exposure to blood or body fluid has occured, the following baseline tests should be obtained (see Table 9 for follow-up according to baseline results):
- HCV antibody test (e.g., EIA/ELISA), and if positive, HCV RNA test
- Liver panel including liver enzymes
- HCV antibody and if positive, HCV RNA test
If the source patient is tested with an EIA/ELISA and found to be positive, then follow-up testing is necessary to confirm the source person’s status. HCV RNA may be used as the confirmatory test. When the source person tests positive with the HCV RNA test, the exposed person should be managed as if the source has chronic HCV.
Clinicians should educate exposed persons about the natural history of HCV infection and should counsel exposed persons about the following:
- Avoidance of alcohol and, if possible, medications that may be toxic to the liver.
- Risk of transmission related to:
- Blood-to-blood contact, including sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes; occupational needlestick injuries; and sharing needles, syringes, or other equipment to inject drugs
- Sexual activity
- Donating blood, plasma, organs, tissue, or semen
- Perinatal transmission
- Hepatitis C virus is not spread via food or water and is not transmitted by:
- Sharing eating utensils
- Hugging, kissing, or holding hands
- Coughing or sneezing
- Breastfeeding: HCV is not transmitted by breastfeeding; however, clinicians should advise women who may have been exposed to HIV to avoid breastfeeding28 for 6 months after the exposure.
Factors that may increase the risk of sexual transmission include sex with multiple partners, history of STIs, including HIV, or any other practice that might disrupt mucous membranes. The potential need for mental health counseling should be anticipated and offered as needed.
2. Post-Exposure Follow-Up for HCV
If the source is known to be positive for HCV antibody and/or HCV RNA, the follow-up schedule for the exposed person should be as follows (AII) :
Week 4: HCV RNA and liver panel
Week 12: HCV RNA and liver panel
Week 24: Liver panel and HCV antibody
If at any time the serum ALT level is elevated, the clinician should repeat HCV RNA testing to confirm acute HCV infection. (AIII)
At any time that exposed persons test positive for HCV RNA, the clinician should refer for medical management and possible treatment by a clinician with experience in treating HCV. (AIII)
For persons exposed to a hepatitis C-infected source, regular follow-up with HCV RNA testing is recommended in addition to HCV antibody testing, because HCV RNA testing can identify acute infection within 2 weeks of exposure, whereas accuracy of the antibody test can be delayed up to several months after acute infection (i.e., “window period”). Seroconversion with the ELISA antibody test occurs in 50% of patients within 9 weeks of exposure, in 80% of patients within 15 weeks of exposure, and in at least 97% of patients within 6 months of exposure.37 The ELISA test is highly sensitive but relatively nonspecific, resulting in a low positive predictive value in low-prevalence populations. Positive HCV ELISA antibody test results require confirmation by a quantitative viral load assay, such as HCV PCR.
IX. RESOURCES FOR CONSULTATION
Persons who have responsibility for providing nPEP may need expert advice and consultation, as well as assistance in helping their clients obtain medication.
The following resources are the preferred initial contacts for expert consultation:
- The National Clinicians’ Consultation Center PEP line at 1-888-HIV-4911 (1-888-448-4911).
For providers in New York State:
- For further education of health providers or for consultation regarding setting up PEP services, contact: CEI PEP, Testing and Diagnosis Center
- To obtain the NYSDOH protocol for sexual assault victims, call the NYSDOH Rape Crisis Program at 518-473-6919.
For information about rape crisis services, see Appendix B.
1. New York State Department of Health AIDS Institute. HIV Prophylaxis Following Occupational Exposure. NYSDOH AI;2004. Available at: www.hivguidelines.org.
2. Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). J Virol 2000;74:9771-9775.
3. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatrics AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994;331:1173-1180.
4. Centers for Disease Control and Prevention. Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood: France, United Kingdom, and United States, January 1988-August 1994. MMWR Morb Mortal Wkly Rep 1995;44:929-933. Available at: www.cdc.gov/mmwr/pdf/wk/mm4450.pdf
5. Kahn JO, Martin JN, Roland ME, et al. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: The San Francisco PEP Study. J Infect Dis 2001;183:707-714.
6. Kwong J, Mayer K, Peterson N, et al. Non-occupational post-exposure prophylaxis (PEP) at a Boston Community Health Center. The XIII International AIDS Conference. Durban, South Africa; 2000.
7. Schechter M, Lago RF, Ismerio R, et al. Acceptability, behavioral impact, and possible efficacy of post-sexual-exposure chemoprophylaxis (PEP) for HIV. 9th Conference on Retroviruses and Opportunistic Infections; Seattle, Washington; February 24-28, 2002.
8. Murphy S, Kitchen V, Harris JR, et al. Rape and subsequent seroconversion to HIV. BMJ 1989;299:718.
9. Myles JE, Hirozawa A, Katz MH, et al. Postexposure prophylaxis for HIV after sexual assault. JAMA 2000;284:1516-1518.
10. Pinkerton FD, Martin JN, Roland ME, et al. Cost-effectiveness of post-exposure prophylaxis after sexual or injection-drug exposure to HIV. Arch Intern Med 2004;164:46-54.
11. Hamers FF, Lot F, Larsen C, et al. Cost-effectiveness of prophylaxis following non-occupational exposure to HIV infection in France. In: Program and Abstracts of the 8th Conference on Retroviruses and Opportunistic Infections; Chicago, Illinois; February 4-8, 2001.
12. DeGruttola V, Seage GR III, Mayer KH, et al. Infectiousness of HIV between male homosexual partners. J Clinical Epidemiol 1989;42:849-856.
13. Varghese B, Maher JE, Peterman TA, et al. Reducing the risk of sexual HIV transmission: Quantifying the per-act risk for HIV on the basis of choice of partner, sex act and condom use. Sex Transm Dis 2002;29:38-43.
14. European Study Group. Comparison of female to male and male to female transmission of HIV in 563 stable couples. BMJ 1992;304:809-813.
15. Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr 1992;5:1116-1118.
16. Centers for Disease Control and Prevention. Management of possible sexual, injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. MMWR Morb Mortal Wkly Rep 1998;47(RR17):1-14. Available at: www.cdc.gov/mmwr/pdf/rr/rr4717.pdf
17. Koh HK, DeMaria A, Mcguire JF. Massachusetts Clinical Advisory. Massachusetts; 2001.
18. Non-Occupational HIV PEP Task Force, Brown University AIDS Program and the Rhode Island Department of Health. Non-occupational human immunodeficiency virus postexposure prophylaxis guidelines for Rhode Island healthcare practitioners. August 1, 2002.
19. Myles JE, Bamberger J, and the California HIV PEP after Sexual Assault Task Force. Offering HIV Prophylaxis Following Sexual Assault: Recommendations for the State of California. San Francisco, CA: Housing and Urban Health of the San Francisco Department of Public Health and the California State Office of AIDS;2001. Available at: http://www.dhs.ca.gov
20. Dillon B, Hecht FM, Swanson M, et al. Primary HIV infections associated with oral transmission. In: Program and Abstracts of the 7th Conference on Retroviruses and Opportunistic Infections; San Francisco, California. January 30-February 2, 2000.
21. Page-Shafer K, Shiboski CH, Dennis H, et al. Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men. AIDS 2002;16:2350-2352.
22. Vidmar L, Poljack M, Tomazic J, et al. Transmission of HIV-1 by human bite. Lancet 1996;347:1762-1763.
23. Pretty I, Anderson G, Sweet D. Human bites and the risk of human immunodeficiency virus transmission. Am J Forensic Med Pathol 1999;20:232-239.
24. Rich JD, Macalino G, Merchant RC, et al. HIV seroprevalence of adult males incarcerated for a sexual offense in Rhode Island, 1994-1999. JAMA 2002;288:164-165.
25. New York State Department of Health AIDS Institute. Promoting Adherence to HIV Antiretroviral Therapy: Best Practices from New York State. Albany, NYSDOH; 2001. Available at: http://www.hivguidelines.org
26. Tsai CC, Emau P, Sun JC, et al. Post-exposure chemoprophylaxis (PECP) against SIV infection of macaques as a model for protection from HIV infection. J Med Primatol 2000;29:248-258.
27. Centers for Disease Control and Prevention. Serious adverse events attributed to nevirapine regimens for postexposure prophylaxis after HIV exposures: Worldwide 1997-2000. MMWR Morb Mortal Wkly Rep 2001;49:1153-1156. Available at: www.cdc.gov/mmwr/pdf/wk/mm4951.pdf
28. Committee on Pediatric AIDS. Infant feeding and transmission of human immunodeficiency virus in the United States. Pediatrics 2013;131;391-396. [PubMed].
29. Weinbaum C, Lyerla R, Margolis HS. Prevention and control of infections with hepatitis viruses in correctional settings: Centers for Disease Control and Prevention. MMWR Recomm Rep 2003;52(RR-1):1-36. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5201a1.htm
30. Beasley RP, Hwang L-Y, Stevens CE, et al. Efficacy of hepatitis B immune globulin for prevention of perinatal transmission of the hepatitis B virus carrier state: Final report of a randomized double- blind, placebo-controlled trial. Hepatology 1983;3:135-41.
31. Szmuness W, Stevens CE, Harley EJ, et al. Hepatitis B vaccine: Demonstration of efficacy in a controlled clinical trial in a high-risk population in the United States. N Engl J Med 1980;303:833-841. [PubMed]
32. Redeker AG, Mosley JW, Gocke DJ, et al. Hepatitis B immune globulin as a prophylactic measure for spouses exposed to acute type B hepatitis. N Engl J Med 1975;293:1055-1059. [PubMed]
33. Papaevangelou G, Roumeliotou-Karayannis A, Richardson SC, et al. Postexposure immunoprophylaxis of spouses of patients with acute viral hepatitis B. In: Zuckerman AJ, ed. Viral Hepatitis and Liver Disease. New York, NY: Alan R. Liss, Inc.; 1988:992-994.
34. Roumeliotou-Karayannis A, Dandolos E, Richardson SC, et al. Immunogenicity of a reduced dose of recombinant hepatitis B vaccine. Vaccine 1986;4:93-94. [PubMed]
35. Perrillo RP, Campbell CR, Strang S, et al. Immune globulin and hepatitis B immune globulin. Prophylactic measures for intimate contacts exposed to acute type B hepatitis. Arch Intern Med 1984;144:81-85. [PubMed]
36. Weinbaum CM, Williams I, Mast EE, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep 2008;57(RR-08):1-20. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm
37. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep 2001;50(RR-5):1-43 Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm
APPENDIX A: ANTIRETROVIRAL DRUGS
The tables that follow include antiretroviral agents recommended for PEP (zidovudine, lamivudine, tenofovir) as well as alternative antiretroviral drugs because the recommended regimen may require alteration based on factors such as prior use of antiretroviral therapy in the person who is the source of the exposure. For information on all antiretroviral medications, see Antiretroviral Therapy. The following tables indicate dosage, toxicity, and dose adjustment recommendations for a 4-week course of prophylaxis. Because there are toxicity and dose adjustment considerations for all of these medications when used for chronic treatment, other references should also be consulted. The tables also include letters that reference FDA pregnancy categories as described below.
FDA Pregnancy Categories
A Adequate and well-controlled studies of pregnant women fail to demonstrate a risk to the fetus during the first trimester of pregnancy (and there is no evidence of risk during later trimesters).
B Animal reproduction studies fail to demonstrate a risk to the fetus and adequate and well-controlled studies of pregnant women have not been conducted.
C Safety in human pregnancy has not been determined, animal studies are either positive for fetal risk or have not been conducted, and the drug should not be used unless the potential benefit outweighs the potential risk to the fetus.
D Positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experiences, but the potential benefits from the use of the drug in pregnant women may be acceptable despite its potential risks.
X Studies in animals or reports of adverse reactions have indicated that the risk associated with the use of the drug for pregnant women clearly outweighs any possible benefit.
APPENDIX B: RAPE CRISIS PROGRAM
The Rape Crisis Program is the only New York State agency-sponsored program that focuses on sexual assault prevention and treatment for survivors of sexual assault. Located within the Bureau of Women’s Health, the Rape Crisis Program’s mission is to support activities to prevent sexual assault and to ensure that services are available, accessible, and appropriate for sexual assault survivors.
The Rape Crisis Program is committed to improving New York State’s response to sexual assault survivors through advocacy, policy development, and coordination and oversight of a statewide network of rape crisis service providers. Technical assistance on sexual assault issues is provided within the NYSDOH, with other State agencies, healthcare facilities, and professional organizations.
The Rape Crisis Program is available at: www.health.ny.gov/community/adults/women/violence/rape_crisis/
The Rape Crisis Providers Report is available at: www.health.ny.gov/community/adults/women/violence/rape_crisis/rape_crisis_provider_report.htm
APPENDIX C: SEXUAL ASSAULT FORENSIC EXAMINER (SAFE) PROGRAM
The Sexual Assault Forensic Examiner (SAFE) program is a collaborative effort in which the Rape Crisis Center works with healthcare providers, law enforcement, and the prosecutor’s office to provide a team approach to meet the needs of the sexual assault survivor. There are three general objectives for sexual assault forensic examiner programs:
- To provide the survivor of sexual violence with victim-centered, sensitive care and treatment.
- To ensure quality evidence collection by a trained healthcare practitioner.
- To provide expert testimony when needed.
Sexual assault forensic examiners are on-call for survivors of sexual assault. They have special education in the following areas:
- forensic interviewing techniques;
- cultural sensitivity;
- elderly, male, and child victims;
- health care of sexual assault survivors (e.g., emergency contraception, treatment for possible exposure to sexually transmitted diseases, and coordination of follow-up services); and
- forensic techniques (e.g., use of the colposcope, forensic photography, screening for the presence of “date rape drugs”).
Together, with the sexual assault victim advocate, this team approach provides comprehensive and holistic health care.
To find out about the availability of sexual assault forensic examiner care in your community, contact your local Rape Crisis Center or Victims Services Agency.
More information about sexual assault forensic examiner programs in New York State is available at: www.health.ny.gov/professionals/safe/, or contact:
New York State Coalition Against Sexual Assault (NYSCASA)
28 Essex Street
Albany, New York 12206
Phone: (518) 482-4222
Fax: (518) 482-4248
Joe Farrell, Director of Training: (518) 482-4222, ext. 310
APPENDIX D: REPORTING RESULTS OF TESTING FOR ANTIBODY TO HEPATITIS C VIRUS


text:
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Through The Looking Glass Lewis Carroll Reference Library Free Ebook Kindle Pdf Epub Download
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How would you describe yourself as an artist?: Actor, Performer
What pronouns do you use?: I normally have people call me he/him, but I like they-them/she-her/ze-zir as well...
How do you define your gender?: Fluid, Julie Andrews + Judy Garland
How do you define your sexuality?: Queer/gay, I don't really like the labels
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What is your favorite thing on your resume?: My improv team... I love improv because it affords me the opportunity to play whomever/whatever I'd like (no restrictions)
What is the musical theatre song you’re most likely to belt in the shower?: "A Call From The Vatican" from ‘Nine’... more recently "The Squip Song" from ‘Be More Chill’
Who is your “queer-o”? : Kate McKinnon, Lady Gaga

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text: This cross-country skiing and horseback riding haven has stunning views and laid-back yet luxurious accommodations. There's a full equestrian center with 40 horses, a beach with kayaks and canoes, and a summer camp for kids. In winter, there are sleigh rides and ski and snowshoe rentals so you can enjoy the 37 miles of trails. Three suites have fireplaces, as do the cabins. The popular dining room restaurant features local foods in a slightly more formal setting; the Highlands Tavern has a casual and cozy pub feel.

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No sooner does Disgaea 2: Dark Hero Days go out the door than NIS America has to send out another message concerning some alarming gamesave notices that players are getting. This time, they'll be rewarded for their needless anxiety.
Gamers were getting some confusing error messages regarding downloadable content, which is strange because the game released yesterday and DLC for it won't be available for two months. However strange, though, no one blows off a message like "If you save now, your save data will be saved in the state in which you cannot use the DLC."
NIS America put out a statement saying they've researched the problem and found that it's an erroneous message, which is supposed to appear if you are saving data with DLC involved, but your Memory Stick doesn't have the corresponding DLC package on it. "The message will appear regardless of whether or not the current saved data contains DLC. Our investigation has revealed that this message will not harm your game play experience with Disgaea 2: Dark Hero Days or any future Downloadable Content offerings."
As a token of their concern for gamers freaked out by these messages, NIS America says its first DLC package, scheduled for Nov. 25, will be free. "Because this message has caused our fans distress and confusion, we have decided to release our first Disgaea 2: Dark Hero Days Downloadable Content free of charge. The DLC content will include the lovely Disgaea 3 princess-to-the-rescue character, Sapphire, and is scheduled for availability on November 25th, 2009."
Awesome! Just keep in mind: "Until then, you will not be able to turn the message off."
NIS America Statement on Disgaea 2: Darkest of Days Error Notices PDF [NIS America, thanks Trygle]


text:
Several gunshots were fired Thursday near Fremont Park following a dispute among about 15 men, sending a pool party scurrying to a nearby restroom for cover and prompting a lockdown of the immediate neighborhood as police searched for the suspects.
No one was reported injured in the shooting, which occurred at about 1:35 p.m. at the park in the 600 block of Hahn Avenue, Glendale Police Sgt. Tom Lorenz said, though police said some of those who fled the scene could have been hit.
At least one bullet pierced the front window of a home across the street from the park in the 600 block of Patterson Avenue, lodging itself in the wall of a family room, police said.
The men — described as being in their late teens and early 20s — were fighting in a parking lot south of the park before the shooting, Lorenz said.
Witnesses reported hearing four to 10 shots, according to police.
A gunman was seen falling to the ground, but he got to his feet and ran east to Burchett Street, police said.
The other men ran to nearby vehicles and fled. The vehicles were described as possibly a light-colored SUV and a black truck.
A pool party was underway at the park when the shooting occurred. A lifeguard rushed the partygoers into a restroom for cover and called police.
Police set up a perimeter and called in the Special Weapons and Tactics team to conduct a search of the park, but no suspects were found.
During the search, police said they found a switchblade knife in the park’s playground.
K-9 units from Glendale and Burbank, as well as a police helicopter, also aided in the search.
The gunman was described as 22 years old and Middle Eastern. He was wearing a white T-shirt and blue jeans, according to police.
Anyone with details about the shooting or the gunman was encouraged to call the Glendale Police Department at (818) 548-3987. To remain anonymous, call Glendale Crime Stoppers at (818) 507-7867.

domain: law


text: The TUSA Mesh Backpack has a generous main compartment built with heavy duty rubberized mesh. The unique extended main zipper provides easy access to all areas within the bag. The main compartment includes an internal zippered pocket. The padded shoulder straps provide comfort while transporting your gear. Easily spot your gear from the crowd with the Hot Pink or Cobalt Blue colors. Also available in black.

domain: design


Most Asian stock markets closed higher on Wednesday, following the release of better-than-expected economic numbers from China.
Mainland Chinese shares were higher on the day. The Shanghai composite rose 0.29 percent to approximately 3,263.12 and the Shenzhen component added around 0.55 percent to about 10,344.43. The Shenzhen composite rose 0.721 percent to close at around 1,772.71.
Hong Kong’s Hang Seng index was largely flat, as of its final hour of trading.
China said Wednesday its economy grew 6.4 percent in the first quarter of 2019, beating analysts’ expectations. A Reuters poll predicted the country’s gross domestic product would grow 6.3 percent year-on-year in the first three months of the year. China grew by 6.4 percent year-on-year in the fourth quarter of last year, and 6.8 percent in the first quarter of 2018.
“China’s high frequency economic indicators confirm that growth is bottoming out,” economists at Australia and New Zealand Banking Group wrote in a note following the data release.
“As the growth momentum of the Chinese economy picks up, we believe that policymakers will re-assess the need for further stimulus,” they said.
The Australian dollar changed hands at $0.7199 following an earlier low of $0.7151. China is Australia’s largest two-way trading partner, according to the latest data from Australia’s Department of Foreign Affairs and Trade.
Investors have been watching the health of the Chinese economy — the world’s second largest — amid Beijing’s ongoing trade dispute with Washington. Official GDP figures are widely followed, but many experts have long expressed skepticism about the veracity of China’s reports.
China also released housing price data on Tuesday, reporting that average new home prices rose faster in March compared to a month earlier, according to Reuters’ calculation of data released by the National Bureau of Statistics.
“The housing data was interpreted as yet another signal that the China’s policy stimuli are beginning to show a positive effect on the economy,” Rodrigo Catril, senior foreign exchange strategist at National Australia Bank, wrote in a morning note.


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Portland man charged with illegal possession of firearmWednesday, September 15, 2021
PORTLAND, Jamaica— Thirty-three-year-old Andrew Bennett is scheduled to appear before the Port Antonio Court on October 20 to answer to gun-related charges stemming from an incident in his community on September 4.
According to the police, at about 12:00 am, a team of officers were on operation in Boundbrook, Port Antonio, Portland when they approached a group of men who opened fire at the officers.
The lawmen returned fire and one man was fatally shot while the other men escaped.
The police say that intelligence led to a raid being conducted and Bennett was taken into custody.
He was interviewed and subsequently charged with shooting with intent, illegal possession of firearm and ammunition following a question and answer session.

domain: news


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Kratos is set to appear as a playable character in the PlayStation 3 version of Mortal Kombat 9. Stickskills.com reported late last night that this will be confirmed in the January issue of Game Informer, which is set to hit newsstands later this week.
Based on what’s been reported, we know that he won’t be playable in single player, but he will have his own move set, fatalities and a God of War themed stage.
The fighting game genre has no shortage of cross-overs, but this is the coolest one in recent memory. I was originally planning on buying the XBOX 360 version of this game, but being able to play as Kratos only on the PS3 is making me think twice. Will the XBOX 360 get its own exclusives?

domain: game


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In part 1 we promised you that we still have more expert opinions in the pipeline, ready to discuss the future of banking and finance and what it holds for us! In the prelude, Nordic hotshot meniga suggested that banks face a real risk of losing their position of power as players like snapchat or WeChat enter in disguise – along with giants like Amazon and thousands of emerging fintechs. However according to meniga, a CODE_n alumnus, making digital banking a drastically better environment as well as gathering speed in providing a top-notch user experience could be a lifeline that allows banks to keep pace with the emerging competitors. What do other players think? Three additional visionary fintechs predict where the digital disruption of the banking and finance sector will lead. But be prepared – they don’t offer easy answers!
The world is becoming smaller every day, not just because of the amazing technological advancements of recent decades, but also because of the way the internet and the digital revolution are eradicating physical and spatial barriers. Things taking place on the other side of the globe suddenly feel like they’re right next door to us – if only those language barriers weren’t still in the way. The CODE_n alumnus Transfluent was founded in the belief that all companies should have an easy way to become global and communicate with their customers in the local language. The conviction of the Finnish startup morphed into a leading translation provider with a global team and solutions that bring them to the forefront of innovative technology. We spoke to the CEO and founder Jani Penttinen about the things that make his business model unique and the journey towards becoming a global, rapidly expanding enterprise. Jani also divulges a couple of personal tips on setting up a successful team and how he successfully pulled together 800k through the crowdfunding platform Invesdor. And that was just the prep work before the planned IPO gets underway! Jani also tells us about the up-and-coming startup scene in Finland.
Banks need to wrap up warmly – the upheaval across the whole sector has only just begun! Cryptocurrencies like Bitcoin and Ethereum are on a mission to revolutionize our monetary system, roboadvisors are superseding human financial advisors using sophisticated algorithms that predict the best personal investment strategy, or transfer money at the click of an icon on your smartphone. And this is just the tip of the iceberg. There is huge potential for disruptive concepts to take us off the beaten track into entirely new realms of banking and finance! The keys to the door for the promising FinTech startups now entering the market are customer service and automation. These two factors are defining current goals, as startups dare to challenge the hegemony of traditional financial services and the age-old banking system. How? By combining cutting-edge technology like blockchain systems, artificial intelligence and big data, and using them to create new and enhanced services for their customers. As part of our Future of Finance and Banking series, we will be looking at this fascinating topic and speaking to some of the “revolutionaries” in the sector. Their aim will be to predict developments in this rapidly evolving market from their standpoint, lifting the lid on visionary FinTech business and gaining insights into the kind of financial world we can expect to experience in the future!
Digital transformation is only for the big players? What a persistent myth. In fact, digitalization holds great opportunities for SMEs and can even level out inequalities between small and big companies. Yet, not all small- and medium-sized enterprises embrace digitalization: A study by IDC from 2016 revealed that only 42% of small businesses worldwide are actively engaged with digital transformation to automate functions, derive real-time insights, and optimize processes for performance gains.
But there is so much to gain! The mentioned study also showed that there is a connection between the state of digital transformation and revenue growth: Whereas 52% of the most fast-growing SMEs stated a rather high progress in digital transformation, only 28% of companies with flat or declining growth declared the same. Still, it is understandable that smaller firms dread bigger investments and the risks that come with it. But standing still is also not an option. Instead, let us look at the major challenges of digitalization for small and medium-sized companies and how they can tackle it!
For a long time, it has been the topic of sci-fi thrillers – now, it’s becoming reality: the robotics revolution. No panic needed though, it looks very different to the way film directors envisioned it. Mechanical men don’t march among us, in fact robots are mainly used in the industry. So, what exactly does the future hold for us? What’s hot in robotics? And most importantly: how are working places going to change in course of the robotic boom? CODE_n got some answers for you and names 3 trends to keep an eye on.
Frankfurt, Hamburg, Berlin, Munich and now Stuttgart – to name just a few! The Federal Ministry of Economics Affairs and Energy recently announced the launch of twelve digital hubs in Germany as part of its Digital Hub Initiative. The aim of the program is to foster collaboration between companies and business entrepreneurs, thus allowing them to work side by side in close quarters, similar to Silicon Valley. The program will also help fuel collaboration between the German startup scene and industry hotspots. An alliance of regional players, GFT Technologies SE and CODE_n among them, formed a consortium that nominated and qualified Stuttgart as a leading digital hub in Germany. The focus: the industries of the future! The Initiative is a great opportunity to bundle the strengths of the lively local startup scenes, international world market leaders and the excellent science in Germany!
Adopting the right approach to digital transformation creates new and exciting opportunities for companies and new ways to shape their own success. But every journey has challenges, especially at established corporations. Equally, even smaller initiatives like trying to promote more digital innovation or adopting new ways of thinking within an organization seem to create obstacles for corporations. Of course, companies have already unearthed a number of potential corporate innovation methods and have learned a lot. But the journey to become a digital pioneer not only involves managing the many different aspects of digital transformation, firms also need access to global networks – experts, experienced pioneers, people who know about tech-related topics, the broader challenges (e.g., engendering an effective culture of innovation), and specific innovation formats (e.g., startup co-creation models).
CODE_n has been a key player in the innovation scene for years and is now opening up its network and experience to established corporations and SMEs. Why? To help them to boost their innovation processes themselves; to allow them to become a digital pioneer under their own steam.
Most of the time, digitalization is the solution to everything, isn’t it? So why shouldn’t it be a solution to the world’s energy problem? But how can digitized processes help to save the planet? Their biggest advantage is helping to a significant reduction in CO2 emissions, while they minimize the need for some resources (i.e. paper) in manufacturing as well as in logistics. The digital transformation of industries can help to avoid an estimated 26 billion metric tons of net CO2 emissions and this only from three industries: electricity, logistics and automotive. So it’s high time we went for it! Since every increase by 1 percent of the global gross domestic product, the world’s carbon emissions rise by an estimated 0.5 percent.
Digital innovations should therefore be taken on account and used against this trend. Because, applied in the right way, digital technology can save lots of energy, even if it sometimes consumes much. Based on some examples, we show you here how easy can it be for a company to save energy and thereby to make the world a whole lot better.

domain: finance


An idyllic stretch of road turns into a dumping ground for a dead body in the latest trailer for FX's upcoming limited series Fargo, which comes just days after the first trailer featuring stars Billy Bob Thornton and Martin Freeman. The 10-episode series is based on a true crime story, centering on Lester Nygaard (Martin Freeman), an insurance salesman whose quiet life is turned upside down when he meets the manipulative Lorne Malvo (Billy Bob Thornton). Check out this brief trailer and stay tuned for more footage as we get closer to the April 15 premiere date.
A 10-episode limited series inspired by the film, FX's Fargo will feature an all-new "true crime" story, with the series following a new case and new characters, all entrenched in the trademark humor, murder and "Minnesota nice" that has made the film an enduring classic. Fargo is written by Noah Hawley. Executive Producers are Joel Coen & Ethan Coen, Warren Littlefield, and Warren Littlefield. Fargo is produced by FX Productions and MGM Television.


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OMAHA, Neb. (KMTV) — Recent budget cuts by the Trump Administration suspended a study that was looking into the declining numbers of honeybees across the nation. America lost millions of them within the last year. Losing high numbers of bees also impacted local beekeepers in Omaha.
"If you get a wet year, you'll see heavier losses than you will a dry year," says Lynn Danzer of the Omaha Bee Club.
Weather was to blame for much of the loss locally. The wet spring caused water to get into the hives, where the water would freeze at night thus killing the bees. Mold would also grow inside hives as well which would poison the bees.
According to a new study from a University of Maryland non-profit, beekeepers across the nation lost 40.7% of their colonies from April 2018 to April 2019. Weather takes blame, but so does the use of pesticides. "They're driven away by the scents and the toxins and they can attract that back to their hive," says Lauren Sitzman, a local beekeeper.
The Omaha Bee Club recommends not using pesticides in your yard, planting native plants in your garden, and buy local honey instead of chain honey. Buying locally means that money goes back to the beekeepers who then use it to help maintain their hives.
If you're interested in learning more about beekeeping, check out Omaha Bee Club on Facebook, or email them at firstname.lastname@example.org.

domain: biology


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The ball keeps rolling down the hill. And now, one of the legacies we pride ourselves with is the inroad of an almajiri economy. It’s implementation pays you stipend for being jobless, not providing you job. Your kids get fed in school and not you getting empowered to feed your kids.
At the last count, the government announced that it has expanded the school kids feeding programme to 14 states and the latest budget stood at N6.2b for those. That translates to about N442m per state and when it must have gone round all states, if it would, then expect a bill of about N16b for all. But what they have not actually told us is what period of time the bill covers. Is it this within the current year’s budget or since inception sometime last year?
While those issues may ot matter so much, what is more compelling is that we have stepped into the era of rearing a beggarly economy where the citizens are coaxed to accept poverty, never labour to make a living, but wait to be paid N5000 every month, although that is still in campaign propaganda and never implemented. But if that holds, though at variance with President Muhammadu Buhari’s defence sometime that the campaign promise wasn’t his, rather that of the APC, then we would have arrived at the point of no return in managing poverty and hardship.
Some days ago in the week, a radio made the schools feeding programme a major matter of discussion. The two lady presenters were so excited that they eulogized the project and did their best to antagonize all callers that spoke about it in the contrary. They canvassed all manner of defence, including that the project creates jobs for the cooks and food vendors. Really?
I asked myself, between feeding school kids and providing schools adequate equipment and learning facilities, which would add more value, even in job creation?
I still wonder why and how jobs would not be created if the FG channels that feeding effort to rebuilding the dilapidated school blocks because the feeding includes those schools where the kids study under trees and in the rain.
If the same government embarks on rebuilding the collapsed structures, providing furniture for the kids that study sitting on bare floor, pay the teachers better, empower them more through training and conducive work environment, equip the laboratories and libraries to make for better quality education, would that cause job losses or creation. I even expect better and more jobs than the canvassed feeding programme.
In good economies, I hear of premium placed on good quality education where the kids’ parents are empowered enough to feed their children. Government elevates the value of education handed the children. That is why even here in Nigeria, the implementers of the same programme don’t have their kids in such schools. They prefer to send their children to schools of quality education and feed them themselves. For the common man, his kids should be fed and no attempt to create liberating possibilities for them to live a better and elevated life and be empowered.
I don’t want to argue on whether the project implementation is as good as what they claim in the news. I rather assume that they are as smooth as announced. So my postulation is that with perfect implementation, it isn’t wiser to impoverish a parent and feed her kids in school. Instead, provide him enabling factors within his economic space and allow her feed her kids?
I am sure so many parents value their honour and living up to their parental obligation through an economy that provides them the opportunities to grow. As a parent, I for one prefer to cater for my children and live in a country with an economy that provides me enablers to live independently rather than be a beggar to the government. I see this approach as easiest way to deceive a people that all is well and create laziness and laxity.
What has kept Nigeria in retardation this long is the culture of money sharing in Abuja. Every month, states gather in Abuja and share money and go back home to spend it and wait for another round of sharing. That has emasculated creativity, industry and thinking. It has encouraged corruption and desperation for power where jostlers for power have their eyes on the pool of money to be shared. All the brigandage to be in power is actually the tussle to occupy the position of sharer-in-chief of the common wealth.
The same retardant is what the government wants to replicate in the education system where struggling families would be held down forever with the deceit their children are fed in schools and nobody would have the time to ask questions on improving the poor and terrible quality of education the masses get. That poor showing and terrible quality of education is replicated at all the tiers – from primary through tertiary and a government that declared that the latest demand of the Academic Staff Union of Universities (ASUU) is more than the budgetary allocation for the entire education sector, implying scarcity of resources, rather prefers to chase shadows and feed children, hold them down in their mind and make them prisoners of poor quality education.
Where is the justification that the government that doesn’t have enough money to fund education, far below the UN standards of 26% of the budget for education prefers feeding children of the poorer citizens rather than liberating their parents to cater for them?
Those children are aware that they are treated as the helpless by feeding them in school and that their fellow kids from rich families are not fed the same way, thereby ingraining in them the inferiority of the downtrodden class and barring them from raising their heads in the company of those privileged kids.
That is why I ask again, if the policy is so wonderful, why are the kids of these implementing government officials not in those schools? It is the same trend in the university system where the powerful citizens that refuse to listen to ASUU don’t have their kids in those universities and even if the teachers go on strike for 10 years, its is none of their business. We heard in the past instances where the children of governors that refuse to negotiate with teachers under their care study abroad.
In my primary school days in Imo State, the governor of my state then, Sam Mbakwe had his daughter in a school in UU and the union of teachers released the money he paid for his daughter in a year as more than the wage bill of all the teachers in a month for which they were on strike. When Governor Chinweoke Mbadijunu was in charge in Anambra State, primary and secondary schools were shut for one year or a little less. During that time, news broke that his daughter of 28 years bagged a PhD in medicine in US.
Sometime in July, we all saw photos of Bukola Saraki, Senate President’s son graduation in UK, an emir’s daughter’s graduation in the UK and also the son of Governor Aminu Tambuwal of Sokoto State in UK. So with the laudable school kids feeding, where are their children in all these? Who is actually deceiving us?
My take remains that this project is just glorified almajiri system by a government that prefers to impoverish us, throw crumbs at us and ensure that we never get the kind of environment that would empower us to pick our bills. It is enslavement. It is wrong and it is counterproductive. Provide my child the right incentives to get quality education and leave his feeding to me. Provide the right facilities that would enable her get quality education to liberate her mind and I would be thankful because that is the duty of the government.

domain: sociology