Harbor:Non-Occupational Exposure

General Guidelines

• Stats on Risk: https://www.wikem.org/wiki/HIV_post-exposure_prophylaxis
• CDC Information: http://stacks.cdc.gov/view/cdc/38856.

Harbor ED Policy

• DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf
• LA County Public Health HIV PEP Recommendations: https://www.wikem.org/wiki/File:SART_-_Public_Health_HIV_PEP.pdf
• Harbor Sexual Assault algorithm and resources: Harbor:Sexual assault
  • Harbor - Detailed "How to" for SART Team: https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
    • Preserve all evidence (skin, urine, clothing) and protect chain of custody; address any life-threatening emergencies as appropriate!
    • Limit detailed documentation of described events to avoid future discrepancies
    • Closest SART Center is in San Pedro. Call sheriffs at Harbor to speak to patient, they will determine precinct in which even happened and contact that local precinct to interview patient and determine if patients meets SART criteria.
    • Forensic Nurse Specialist (SART Staff) available 24/7 at (562) 497-0147
      • Los Angeles SART Centers: https://www.wikem.org/wiki/File:SART_Centers.pdf
      • OLD Resource of SART list https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Sexual%20Assault%20Protocol.pdf

• High-risk HIV exposure: shared needles with HIV+ person, or partner or assailant in the case of sexual assault has unknown HIV status, is known HIV+ or highly likely to be HIV+ with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma, occurring within the prior 72 hours.
  • Sexual assault victims should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI testing and prophylaxis. Can consider offering Plan B contraception if patient is not NPO for evidence collection.
    • If the patient meets these criteria, then first dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's 48 hours of medications to go home with to tie them over until they can get the 28d course needed from a PEP center.
    • For the vast majority of cases in which a patient seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center http://getprepla.com/PEP/Get-PEP-Now/ to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center. The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure. Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).
    • If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional CBC, BMP, LFTs, Hep screen (Hep A IgG, Hep B sAg, sAb, cAb, and Hep C Ab), needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV or infectious disease team at your site, or the National Clinical Consultations Center’s PEPline at (888) 448-4911

See Also

• Harbor:Main
• Harbor:Sexual assault