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
Chapter 11:
Postexposure Prophylaxis
OVERVIEW
INTERVENTIONS FOR PEP IN HEALTH CARE SETTINGS
INTERVENTIONS FOR NONOCCUPATIONAL PEP (NPEP)
HIV 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 of HIV with rapid initiation of short-term
antiretroviral therapy (ART) following occupational or
nonoccupational exposure. PEP should be considered
in all health care personnel (HCP) and non-HCP
exposed to 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 of immune globulin and vaccination
when indicated.
PEP policies should be instituted in all health care
settings. The essential elements include:
• Written protocols for documenting and managing
exposures
• Assessment, counseling, and intervention
immediately after any exposure
• Rapid access to medications and/or immunization,
if indicated
What do we know about the effectiveness
of PEP for HIV?
Retrospective case-control studies support the efficacy of
PEP for occupational exposure to HIV, and 4 factors are
associated with increased transmission rates: 1) deep
injury, 2) visible blood on device, 3) needle placement
in artery or vein, and 4) late stage HIV disease in source
(this risk factor was identified prior to viral load testing,
thus high viral load is likely an independent risk factor).
Evidence of the effectiveness of nonoccupational PEP
comes from small observational human studies,
extrapolation of data showing the interruption of
maternal-infant transmission, and animal studies
showing some degree of protection from genitally
and intravenously acquired HIV. Even with optimal
implementation, the degree of protection afforded by
PEP is incomplete. Studies of PEP have demonstrated
the greatest reduction in HIV transmission when
antiretroviral medications are administered immediately
after exposure to HIV-infected blood and body fluids.
The efficacy of PEP is diminished after 36 hours and is
minimal after 72 hours.
What do we know about the effectiveness
of PEP for hepatitis B and C?
Hepatitis B transmission can be prevented through
administration of immune globulin and hepatitis B
vaccine. PEP for hepatitis C virus (HCV) has thus far
proven to be ineffective.
What body fluids are infectious for HIV,
HBV, HCV?
Blood is the most infectious body fluid. In the health
care setting, cerebrospinal, synovial, pleural, peritoneal,
pericardial, and amniotic fluids are all considered
potentially infectious, although the only documented
cases of occupational HIV infection have been with
blood, body fluids with visible blood, or HIV viral
cultures. Unless there is visible blood with the exposure,
saliva, nasal discharge, tears, sweat, vomit, urine, and
feces are not infectious. Semen and vaginal secretions
are infectious for HIV, HBV, and HCV in the setting of
nonoccupational exposure.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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