HIV post-exposure prophylaxis

Background
  • Also known as HIV Post-Exposure Prophylaxis (PEP)
  • Probability of HIV transmission from a percutaneous needle stick is approximately 0.3% (1 in 300) and 0.09% from mucous membrane exposure.[1][2]
  • ~79% transmission reduction
  • Common side-effects = constitutional, gastrointestinal

Timing and Duration of PEP[3]
  • Initiate ASAP (goal = <2 hours after exposure)
  • >36 hours: normally deferred, unless particularly high risk
  • PEP is likely to be less effective when started more than 72 hours after exposure, but the interval after which no benefit is gained from PEP for humans is undefined.
  • If initiation is delayed, the likelihood increases that benefits might not outweigh the risks inherent in taking antiretroviral medications.
  • Initiating therapy after a longer interval (eg, 1 week) might still be considered for exposures that represent an extremely high risk of transmission

CDC recommendations

From 2013 recommendations [4]

  • PEP is recommended when occupational exposures to HIV occur
  • PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and continued for a 4-week duration
  • New recommendation - PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
  • New recommendation - if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure; if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

National Clinician's Post-Exposure Prophylaxis Hotline
  • 1-888-448-4911, call for expert advice

Evaluation of Transmission Risk

Exposure Transmission Risk
Exposure^
 Risk
Percutaneous 0.3%
Mucocutaneous 0.09%
Needle-sharing injection drug 0.7%
Receptive anal intercourse 0.5%
Receptive penile-vaginal intercourse 0.1%
Insertive anal intercourse 0.07%
Insertive penile-vaginal intercourse 0.05%
Receptive oral (male) intercourse 0.01%
Insertive oral (male) intercourse 0.005%

^assumes no condom use

High Risk Exposures

Source

  • Symptomatic HIV/AIDS
  • Acute seroconversion
  • High viral load

Exposure

  • Deep injuries
  • Visible blood on device
  • Injuries sustained placing a catheter in a vein/artery

Low Risk Exposures
  • Dried blood on an old needle
  • Human Bites

Workup

Source-Patient
  • Rapid HIV Test
    • HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP[5]

Exposed-Patient

Only if giving PEP (before initiation):

  • CBC
  • Chem 7
  • LFTs
  • Pregnancy test

Management

Negligible Risk
  • NOT recommended

Substantial Risk

Preferred HIV PEP Regimen[6][7]

PEP should be started as soon as possible after significant exposure and continued for 28 days[8]

  • Raltegravir (Isentress; RAL) 400 mg PO twice daily, plus
  • Truvada, 1 PO once daily (Tenofovir DF [Viread; TDF] 300 mg emtricitabine [Emtriva; FTC] 200 mg)

Other Considerations

  • If known source patient with resistant HIV strain, consult HIV service for source-patient-specific PEP
  • Consider interactions with current medication interactions and contraindications, such as renal impairment with Truvada

Pregnant Patients
  • "Expert consultation should be sought in all cases"[9]

Disposition
  • Outpatient, with close follow-up for exposed persons that includes:[10]
    • Counseling
    • Baseline and follow-up HIV testing
    • Monitoring for drug toxicity
    • Follow-up appointments should begin within 72 hours of an HIV exposure

See Also

http://ph.lacounty.gov/dhsp/prep-pep-actionkit.htm

References
  1. Marcus R. et al. CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med. 1988. 319: 1118–1123.
  2. Bell D.M. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997. 102: 9–15.
  3. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  4. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  5. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  6. Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271
  7. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
  8. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  9. Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271
  10. Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
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