A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 11: Postexposure Prophylaxis
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Unfortunately, resistance test results are often
unavailable at the time of the consideration of PEP,
and PEP should not be unduly delayed while this
information is sought. A thorough drug, adherence, and
HIV history from the source patient and consultation
with an HIV expert is needed to make the optimal
treatment recommendation.
When should expert consultation be sought?
Expert consultation is potentially valuable in many
circumstances with PEP. As above, expert consultation
is indicated in the setting of known or suspected drug
resistance in the source in order to select drugs to
which the patient’s virus is likely to be susceptible.
Other situations include:
• Delayed report of exposure, since the interval after
which there is no benefit from PEP is undefined, in
order to determine if PEP is still indicated
• Unknown status of the source, since the decision
regarding the use of PEP should be individualized,
based on the estimated likelihood of risk to the HCP,
considering the severity of the exposure and the
epidemiologic likelihood of HIV exposure
• Known or suspected pregnancy in the exposed
person, in which case specific treatment
recommendations may require modification
• Possible toxicity of the initial PEP regimen, in which
case modification of the regimen and/or treatment of
the adverse side effect may be considered
HEPATITIS PEP
TREATMENT
RECOMMENDATIONS
What are the treatment recommendations and
options for possible hepatitis B exposure?
HBIG and immunization against HBV following
exposure are the most effective methods to prevent
HBV transmission (see Table 11-10). PEP for HBV with
multiple doses of HBIG has been shown to be 75%-
95% effective. Pregnant women can safely receive both
the HBV vaccination and HBIG. When considering PEP
for HBV exposures, both the source patient’s HbsAg
status and the exposed person’s vaccination status and
antibody response should be considered. Both HBIG
and the hepatitis B vaccine should be administered
within 24 hours of exposure. Anti-HBs should be drawn
1-2 months after completion of the third vaccine, but it
is unreliable if the exposed person has received HBIG
within the past 3-4 months.
Table 11-10. Recommended Postexposure
Prophylaxis for Exposure to Hepatitis B Virus
Vaccination
and antibody
response
status of
exposed
workers*
Unvaccinated
Previously vaccinated
Known
responder**
Source
HBsAg positive +
HBIG § x 1 and
initiate HR vaccine
series
No treatment
Known
HBIG x 1
nonresponder Ø and initiate
revaccination or
HVIG x 2 †
Antibody response
unknown
Test exposed
person for anti-
HBs
1. If adequate,**
no treatment is
necessary
2. If inadequate Ø ,
administer HBIG x 1
and vaccine booster
Treatment
Source
HBsAg +
negative
No
treatment
No
treatment
No
treatment
Source of
unknown or
not available
for testing
No Treatment
If know high risk
source, treat as
if sources were
HBsAg positive
Test exposed
person for anti-
HBs
1. If adequate ,
no treatment is
necessary
2. If inadequate ,
administer
vaccine booster
and recheck titer
in 1-2 months
* Persons who have previously been infected with HBV are immune to
reinfection and do not require postexposure prophylaxis.
+ Hepatitis B surface antigen.
§ Hepatitis B immune globulin; dose is 0.06 mL/kg intramuscularly.
Hepatitis B vaccine.
** A responder is a person with adequate levels of serum antibody to HBsAg
(ie, anti-HBs ≥ 10mlU/mL).
Ø A nonresponder is a person with inadequate response to vaccination (ie,
serum anti-HBs < 10mlU/mL).
† The option of giving one dose of HBIG and reinitiating the vaccine series
is preferred for nonresponders who have not completed a second 3-dose
vaccine series. For persons who have previously completed a second vaccine
series but failed to respond, two doses of HBIG are preferred.
Antibody to HBsAg.
Source: Centers for Disease Control and Prevention. Updated U.S. Public Health
Service Guidelines for the Management of Occupational Exposures to HBV,
HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR
2001;50(RR11):22.
What are the treatment recommendations and
options for possible hepatitis C exposure?
There are no recommended prophylactic treatments
after exposure to HCV blood or body fluids. Current
data do not support treatment during acute HCV
infection at this time; referral of an individual with
recently acquired HCV to a specialist in HCV care is
appropriate.
Following exposure, testing should be performed
on the source for anti-HCV. If positive, the exposed
person should be tested for anti-HCV and alanine
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau