A <strong>Guide</strong> <strong>to</strong> <strong>Primary</strong> <strong>Care</strong> <strong>of</strong> <strong>People</strong> <strong>with</strong> <strong>HIV</strong>/<strong>AIDS</strong> Chapter 10: Abnormal Labora<strong>to</strong>ry Values in <strong>HIV</strong> Disease REFERENCES Ragni MV, Belle SH, Im K, et al. Survival <strong>of</strong> human immunodeficiency virus-infected liver transplant recipients. J Infect Dis. 2003;188:1412-20. 10 84 U.S. Department <strong>of</strong> Health and Human Services, Health Resources and Services Administration, <strong>HIV</strong>/<strong>AIDS</strong> Bureau
A <strong>Guide</strong> <strong>to</strong> <strong>Primary</strong> <strong>Care</strong> <strong>of</strong> <strong>People</strong> <strong>with</strong> <strong>HIV</strong>/<strong>AIDS</strong> Chapter 11: Postexposure Prophylaxis Chapter 11: Postexposure Prophylaxis OVERVIEW INTERVENTIONS FOR PEP IN HEALTH CARE SETTINGS INTERVENTIONS FOR NONOCCUPATIONAL PEP (NPEP) <strong>HIV</strong> PEP TREATMENT RECOMMENDATIONS HEPATITIS PEP TREATMENT RECOMMENDATIONS Renslow Sherer, MD Bruce D. Agins, MD, MPH Caroline J. Teter, PA-C, MPH KEY POINTS SUGGESTED RESOURCES REFERENCES CASES OVERVIEW What is postexposure prophylaxis (PEP)? Postexposure prophylaxis (PEP) prevents or aborts transmission <strong>of</strong> <strong>HIV</strong> <strong>with</strong> rapid initiation <strong>of</strong> short-term antiretroviral therapy (ART) following occupational or nonoccupational exposure. PEP should be considered in all health care personnel (HCP) and non-HCP exposed <strong>to</strong> blood or potentially infectious body fluids via percutaneous, mucous membrane, and nonintact skin exposures, injection drug use, intentional or unintentional sexual exposures, and human bites. Hepatitis B infection may be prevented following administration <strong>of</strong> immune globulin and vaccination when indicated. PEP policies should be instituted in all health care settings. The essential elements include: • Written pro<strong>to</strong>cols for documenting and managing exposures • Assessment, counseling, and intervention immediately after any exposure • Rapid access <strong>to</strong> medications and/or immunization, if indicated What do we know about the effectiveness <strong>of</strong> PEP for <strong>HIV</strong>? Retrospective case-control studies support the efficacy <strong>of</strong> PEP for occupational exposure <strong>to</strong> <strong>HIV</strong>, and 4 fac<strong>to</strong>rs are associated <strong>with</strong> increased transmission rates: 1) deep injury, 2) visible blood on device, 3) needle placement in artery or vein, and 4) late stage <strong>HIV</strong> disease in source (this risk fac<strong>to</strong>r was identified prior <strong>to</strong> viral load testing, thus high viral load is likely an independent risk fac<strong>to</strong>r). Evidence <strong>of</strong> the effectiveness <strong>of</strong> nonoccupational PEP comes from small observational human studies, extrapolation <strong>of</strong> data showing the interruption <strong>of</strong> maternal-infant transmission, and animal studies showing some degree <strong>of</strong> protection from genitally and intravenously acquired <strong>HIV</strong>. Even <strong>with</strong> optimal implementation, the degree <strong>of</strong> protection afforded by PEP is incomplete. Studies <strong>of</strong> PEP have demonstrated the greatest reduction in <strong>HIV</strong> transmission when antiretroviral medications are administered immediately after exposure <strong>to</strong> <strong>HIV</strong>-infected blood and body fluids. The efficacy <strong>of</strong> PEP is diminished after 36 hours and is minimal after 72 hours. What do we know about the effectiveness <strong>of</strong> PEP for hepatitis B and C? Hepatitis B transmission can be prevented through administration <strong>of</strong> immune globulin and hepatitis B vaccine. PEP for hepatitis C virus (HCV) has thus far proven <strong>to</strong> be ineffective. What body fluids are infectious for <strong>HIV</strong>, HBV, HCV? Blood is the most infectious body fluid. In the health care setting, cerebrospinal, synovial, pleural, peri<strong>to</strong>neal, pericardial, and amniotic fluids are all considered potentially infectious, although the only documented cases <strong>of</strong> occupational <strong>HIV</strong> infection have been <strong>with</strong> blood, body fluids <strong>with</strong> visible blood, or <strong>HIV</strong> viral cultures. Unless there is visible blood <strong>with</strong> the exposure, saliva, nasal discharge, tears, sweat, vomit, urine, and feces are not infectious. Semen and vaginal secretions are infectious for <strong>HIV</strong>, HBV, and HCV in the setting <strong>of</strong> nonoccupational exposure. 11 U.S. Department <strong>of</strong> Health and Human Services, Health Resources and Services Administration, <strong>HIV</strong>/<strong>AIDS</strong> Bureau 85
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