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

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A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis 11 Table 11-5. Laboratory Evaluation and Followup of Exposed Health Care Personnel Lab tests Comment Frequency HIV antibody test HBV Anti HCV Liver enzymes CBC, renal function, and hepatic function Test HCP if source patient is HIV positive regardless of whether PEP is given Test if source patient is HBsAg or HBeAg positive Test if source patient is HCV positive Test if source patient is HCV positive If PEP is warranted Baseline, 6 weeks, 12 weeks, 6 months (rapid test at baseline, if possible) Baseline and 4-6 months ( or 1-2 months after last HBV vaccine) Baseline and 4-6 months; HCV RNA at 4-6 weeks is optional Baseline and 4-6 months Prior to initiating PEP and repeated in 2 weeks Are there special considerations for PEP in dental settings? Although the number of exposures is relatively high in dental settings, the risk of transmission is low and no different from other HCP settings. Factors that are associated with increased risk of transmission are failure to follow PEP protocols, failure to use punctureproof containers, treating >20 patients per day, failure to use eye protection or masks, and male gender. For more information, see Suggested Resources. INTERVENTIONS FOR NONOCCUPATIONAL PEP (NPEP) What is the role of nPEP for nonoccupational exposure? PEP for nonoccupational exposure to HIV (nPEP) is routinely being administered in cases of sexual assault in hospital emergency departments and is increasingly being made available during other cases of sexual exposure or injection drug use exposure and in nonhospital settings. This issue is particularly relevant in the care of HIV discordant couples. Research on risk of HIV transmission from a single nonoccupational exposure is relatively lacking compared with occupational exposures (see Table 11-6). A national registry has been developed to gather the data with which to develop a CDC recommendation for HIV PEP in the nonoccupational setting. Information about this registry can be found at http://www.hivpepregistry.org. In general, PEP for non-HCP is modeled after PEP interventions and procedures for HCP. Table 11-6. Estimated Risk of HIV Transmission Following Different Types of Exposures Type of exposure Needle-sharing exposure with an infected source Receptive anal intercourse with an infected source Receptive vaginal intercourse with an infected source Insertive anal intercourse with an infected source Insertive vaginal intercourse with an infected source Oral sex with ejaculation with an infected source 0.67% Estimated risk 0.5%-3.0% 0.1% 0.065% 0.05% Conflicting data; however, risk is considered to be extremely low (
A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis What is the role of PEP for discordant couples? Discordant couples (couples in which one person is infected and the other is not) should be routinely educated about how to protect the noninfected person. Both partners should be made aware of the possible effectiveness of PEP in cases of intended or unintended exposures and the importance of early initiation of PEP if it is to be used. Repeated, frequent exposures should signal providers to exercise caution about administration of PEP, since PEP should not be a substitute for avoidance of high-risk behavior. Any request for PEP should prompt additional counseling and psychosocial support to enhance behaviors to prevent HIV infection. What is the role of PEP following sexual assault? Persons who have been sexually assaulted should be considered at risk for HIV and HBV, as well as other STDs. The decision to begin PEP should not be based on the perpetrator’s likelihood of infectivity or delayed pending the test results of the source (unless immediately available). Pregnancy is an important consideration when considering PEP, and emergency contraception should be considered for women who have been sexually assaulted. A survivor of sexual assault may have had multiple exposures. When considering PEP, the most recent exposure should be considered, and PEP should be initiated if the exposure took place within 72 hours before the patient arrived at the health care facility. As with any consideration for PEP, weighing the benefits of PEP versus the possibility of medication side effects, the importance of completing the 28-day regimen and adherence issues should all be considered. The provider should be sensitive to the psychosocial needs of the person who was sexually assaulted; the patient may not be physically or emotionally able to weigh the pros and cons about beginning PEP. Therefore, it is important to follow up within 24 hours to either emphasize the importance of adherence or to continue the discussion about initiating PEP if is to occur within the 72-hour window. See Suggested Resources for more information and resources in addressing issues of sexual assault. What if the person who is exposed is a minor? In cases involving minors, parental or guardian participation is extremely important, but parental or guardian consent for PEP may not be required. Nonetheless, in all cases, parental or guardian participation should continue to be sought in the emergency situation and during followup. State laws and hospital policy must be considered. HIV PEP TREATMENT RECOMMENDATIONS If PEP is found to be appropriate, what information does the exposed person need regarding treatment? The exposed person must understand the risks and benefits of HIV PEP, potential medication toxicities and side effects, instructions on how and when to take the medication, and the importance of adherence to the regimen, including completing the course of 28 days. Women should understand pregnancy-associated risks, including perinatal transmission and teratogenicity. Breast-feeding should be discontinued until the woman receives an HIV-negative result 6 months after exposure. What are HIV treatment recommendations and options for PEP? Currently recommended regimens are shown in Tables 11-7, 11-8, and 11-9; however, these recommendations may be altered if the source patient has a history of ART or known viral resistance, is pregnant, breastfeeding, has hepatic or renal disease, or is taking certain medications. If viral resistance in the source patient is known or suspected, an HIV expert should be consulted prior to initiating HIV PEP medications. Basic HIV PEP regimens include 2 NRTIs. These regimens are relatively simple, ie 1 or 2 pills twice a day, well tolerated, and of sufficient potency to meet the needs of PEP. However, they are substantially less potent than 3-drug regimens. As noted below, some experts, including the authors, believe that only 3-drug regimens should be used for PEP, particularly in the current era of greatly simplified and somewhat better tolerated 3-drug regimens. Three-drug regimens, comparable to highly active antiretroviral therapy (HAART) regimens used to treat HIV infection, are recommended for more severe exposures, which carry a higher risk of HIV transmission, or with exposures to sources with known HIV resistance mutations. The 3-drug regimens increase the risk of medication toxicity and may worsen adherence, all of which should be weighed when choosing an HIV PEP regimen. The majority of exposures in the past have resulted in the administration of 2 medications; 3-drug regimens 11 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 89
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