USPHS Updates Occupational HIV Post-Exposure Prophylaxis Guidelines

Hopkins HIV Report 2006 Jan; 18(1):xx

Assessment

Documentation of the nature and degree of the exposure and the HIV status of the source patient is critical. Rapid testing of previously untested source patients is valuable in determining the need for PEP. The need for PEP and potential number of drugs may be determined by using Table 2 on p 10.

Initiation of HIV PEP

Initiate PEP as soon as possible, preferably within hours after exposure, and continue for 4 weeks. From a practical point-of-view, PEP should be initiated if the source is HIVinfected or thought to be infected, especially if the results of HIV serology are likely to be delayed; PEP may be discontinued if the source is later determined to be uninfected. The current recommended PEP regimens are listed in Table 3 on p 10.

The following drugs are not recommended because of the potential for adverse events: abacavir, delavirdine, zalcitabine, didanosine with stavudine, and nevirapine. During pregnancy avoid efavirenz because of the risk of teratogenic effects and avoid the combination didanosine with stavudine because of toxicity concerns. Additionally, indinavir should be avoided because of the potential for side effects in the newborn.

Health care workers taking PEP report adverse reactions at the rate of 17% to 47%. The most frequently reported reactions were nausea– 27%, malaise and fatigue– 23%. Of 503 HCW who prematurely (<28 days) stopped PEP 24% did so because of adverse reactions. Regardless, the HCW should be advised on the need to complete the 4-week course of PEP. These data came from HCWs who primarily took zidovudinecontaining regimens. The new guidelines now include alternatives to zidovudine, which may be better tolerated.

Expert Consultation

Consultation with an expert in HIV exposures and PEP is encouraged especially in the following instances:

• Initiation of PEP is delayed to >24-36 hrs post-exposure
• The status of the source patient is unknown
• The HCW is currently pregnant or is breastfeeding
• The source patient is known to have a resistant HIV strain
• There are toxicity problems in the initiated regimen

Monitoring

• Re-evaluate HCW at 72 hours, especially if additional information becomes available about the status of the source.
• HIV serologic testing should be conducted at baseline, and then at 6 weeks, 12 weeks and 6 months after exposure. If the HCW experiences hepatitis C seroconversion after exposure, then HIV serology should be repeated 12 months after exposure.
• Tests for HIV (p24 Ag or HIV PCR) in HCW are not routinely recommended due to potential for false positive results; these tests are indicated if there are symptoms compatible with the acute retroviral syndrome.
• Toxicity monitoring.

Laboratory

CBC, liver and renal function tests at baseline and at 2 weeks. HCWs given protease inhibitors should also have a blood glucose at baseline and 2 weeks. HCWs given indinavir should also have urinalysis, monitoring for crystalluria and hematuria.

Self Report

HCWs should be advised to report rash, fever, back or abdominal pain, dysuria, blood in urine, and symptoms of hyperglycemia. They should also be counseled on the possibility of drug interactions and advised to report these should they occur.

Prevention Warnings

HCWs with exposure to HIV should be counseled on measures to prevent secondary transmission, especially in the first 6-12 weeks post-exposure, including avoidance of blood or tissue donations, avoidance of pregnancy and breastfeeding, and use of condoms to prevent sexual transmission.

Seroconversions

Report any seroconversion to CDC at 1-800-893-0485

Resources

The following resources are available for consultation regarding HIV PEP:

PEPline
http://www.ucsf.edu/hivcntr/Hotlines/PEPline
Telephone: 1-888-448-4911

HIV Pregnancy Registry

Telephone: 1-800-258-4263
Email – registry@nc.crl.com

FDA (for reporting unusual or severe toxicity to antiretroviral agents)
http://www.fda.gov/medwatch
Telephone: 800-332-1088

CDC (for reporting HIV infections in HCP and failures of PEP)
Telephone: 800-893-0485

HIV/AIDS Treatment Information Service at
http://aidsinfo.nih.gov

2006-01-10
HHR-2006-01-04

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