What is the protocol for Antiretroviral (ARV) therapy after a dog bite in India?

Protocol for Antiretroviral (ARV) Therapy After Dog Bite in India

Antiretroviral therapy is NOT indicated following dog bites in India; instead, rabies post-exposure prophylaxis (PEP) is the standard of care. Dog bites require rabies prevention measures, not HIV medications.

Proper Management of Dog Bites in India

Immediate Wound Care

• Thoroughly wash the wound with soap and water for 15 minutes 1
• Use a virucidal agent (e.g., povidine-iodine solution) to irrigate the wounds if available 2
• Do not close infected wounds 3

Assessment of Rabies Risk

1. Evaluate the biting animal:

   • Vaccination status of the dog
   • Circumstances of the bite (provoked vs. unprovoked)
   • Whether the dog can be observed for 10 days 2, 3

2. Categorize the bite wound:

   • Category I: Touching/feeding animals, licks on intact skin
   • Category II: Minor scratches or abrasions without bleeding, nibbling of uncovered skin
   • Category III: Single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membranes with saliva 4

Rabies Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Individuals:

1. Rabies Immune Globulin (RIG):

   • Administer 20 IU/kg body weight 2
   • Infiltrate the full dose around and into the wound(s) if anatomically feasible
   • Any remaining volume should be administered intramuscularly at a site distant from vaccine administration 2

2. Rabies Vaccine:

   • Human Diploid Cell Vaccine (HDCV) or Purified Chick Embryo Cell Vaccine (PCECV)
   • Standard regimen: 1.0 mL IM (deltoid area) on days 0,3,7, and 14 2
   • For immunosuppressed patients: Additional dose on day 28 2

For Previously Vaccinated Individuals:

• No RIG required
• Vaccine only: 1.0 mL IM (deltoid area) on days 0 and 3 2

Additional Considerations

• Tetanus prophylaxis if vaccination status is outdated (>5 years) or unknown 3
• Broad-spectrum antibiotics for infected wounds (Amoxicillin-clavulanate preferred) 3
• Follow-up within 24-48 hours to assess for signs of infection 3

Challenges in India

• High incidence of animal bites (1.7% annually), with 91.5% from dogs 5
• Poor compliance with rabies PEP (only 52.3% compliance with ARV and 49.4% with RIG) 4
• Limited availability of RIG due to high cost 6
• Continued use of neural tissue vaccines in some public sector facilities, despite their serious side effects 7
• Prevalent use of indigenous treatments (45.3%) instead of proper medical care 5

Important Pitfalls to Avoid

1. Do not administer rabies vaccine in the gluteal area - this can result in diminished immune response and vaccine failure 2
2. Do not delay treatment - although not an emergency, PEP should be initiated as soon as possible after exposure 2
3. Do not skip wound cleaning - proper wound cleansing can significantly reduce viral load at the exposure site 3
4. Do not exceed recommended RIG dose - excessive RIG may suppress active antibody production 2
5. Do not confuse rabies PEP with antiretroviral therapy - these are completely different treatments for different diseases

Remember that rabies is 100% fatal once symptoms appear, but nearly 100% preventable with proper post-exposure prophylaxis. Ensuring complete compliance with the vaccination schedule is critical.