HIV post-exposure prophylaxis

Background

• Probability of HIV transmission from a percutaneous needle stick is approximately 0.3% (1 in 300) and 0.09% from mucous membrane exposure.
• Also known as HIV Post-Exposure Prophylaxis (PEP)
• ~79% transmission reduction
• Initiate ASAP (goal = <2 hours after exposure)
• >36 hours: normally deferred, unless particularly high risk
• Common side-effects = constitutional, gastrointestinal

CDC recommendations

From 2013 recommendations

• PEP is recommended when occupational exposures to HIV occur
• HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP
• 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
• Close follow-up for exposed personnel should be provided that includes
  • Counseling
  • Baseline and follow-up HIV testing
  • Monitoring for drug toxicity
  • Follow-up appointments should begin within 72 hours of an HIV exposure
• 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

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

Exposed-Patient Workup

Only if giving PEP (before initiation):

• CBC
• C7
• LFTs
• Pregnancy test

Management

Percutaneous Injuries

Superficial wound or solid needle

• If HIV+ source asymptomatic or if viral load <15000 RNA/mL give basic regimen
• If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
• If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)

Deep wound or hollow needle

• If HIV+ source asymptomatic or if viral load <15000 RNA/mL give expanded regimen
• If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
• If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)

Mucous Membrane Exposure

Small volume (few drops)

• If HIV+ source asymptomatic or if viral load <15000 RNA/mL consider basic regimen
• If HIV+ with AIDS, acute seroconversion or high viral load give basic regimen
• If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)

Large volume (splash)

• If HIV+ source asymptomatic or if viral load <15000 RNA/mL give basic regimen
• If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
• If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)

Treatment Regimens

Negligible Risk

• NOT recommended

Substantial Risk

Preferred HIV PEP Regimen

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

• 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
  • For patients with creatinine clearance <60mL/min, consider Raltegravir 400mg PO twice daily, plus Zidovudine and Lamivudine with doses adjusted to the degree of renal dysfunction.
• If the source exposure does report exposure to HIV within the last 6 weeks, HIV RNA PCR (HIV viral load) should be sent along with HIV Ag/Ab screen on the source and nPEP should be initiated for the exposed patient
  • If both tests result not detected and nonreactive, respectively, nPEP should be discontinued.
  • If the source is willing and able to be tested and is found to be HIV-negative with no recent high-risk exposures to HIV, nPEP is not indicated and should not be initiated, or discontinued if already started.
  • The exposed patient still warrants baseline HIV testing and should be offered baseline and follow-up testing for other transmissible infections, e.g. hepatitis A, B, and C, syphilis, chlamydia, and gonorrhea.

Pregnant Patients

• Same as above

Disposition

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

External Links

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

See Also

• Occupational exposure
• Sexual assault
• Hepatitis B
• HIV testing (in California)
• Harbor:Occupational exposure
  • Harbor:Occupational exposure (dot-phrases)