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2–14 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Laboratory Testing
Provide pretest counseling and perform a baseline HIV
antibody test. Evaluate and test for other infections
transmitted through sexual or IDU exposures, including
chlamydia, gonorrhea, syphilis, herpes simplex virus
infection, hepatitis B (HBV surface antigen, surface
antibody, core antibody), and hepatitis C (HCV
antibody). Obtain complete blood count (CBC), liver
function tests (LFTs), and chemistry panel at baseline
before treatment with ARV medications.
Treatment
Follow the algorithm in Figure 1 to determine whether
Table 1. Antiretroviral Regimens for Nonoccupational Postexposure Prophylaxis of HIV Infection
Preferred Regimens
NNRTI-based Efavirenz*+ (lamivudine or emtricitabine) + (zidovudine or tenofovir)
the patient should be offered nPEP medications. If the
patient is a candidate for treatment, counsel him or her
about the potential risks and benefits of nPEP. If the
patient elects to start therapy, see Table 1 for potential
regimens. Select a regimen that is likely to be effective
but tolerable; consider the potential adverse effects of
ARV agents. Note that certain ARV agents, including
nevirapine, should not be used for PEP. Avoid efavirenz
in pregnant women.
If the HIV status of the source person is unknown and
the exposure is considered to be of relatively low risk,
consider 2-drug nPEP (eg, zidovudine + lamivudine)
to minimize toxicity. If the source person is known or
suspected to have infection with HIV that is resistant to
ARV medications, seek expert consultation in selecting
an appropriate nPEP regimen.
PI-based Lopinavir/ritonavir (co-formulated as Kaletra) + (lamivudine or emtricitabine) plus zidovudine
Alternative Regimens
NNRTI-based Efavirenz + (lamivudine or emtricitabine) + abacavir or didanosine or stavudine #
PI-based Atazanavir + (lamivudine or emtricitabine) + (zidovudine or stavudine or abacavir or didanosine) or (tenofovir plus ritonavir
[100 mg/day])
Fosamprenavir + (lamivudine or emtricitabine) plus (zidovudine or stavudine) or (abacavir or tenofovir or didanosine)
Fosamprenavir/ritonavir § + (lamivudine or emtricitabine) + (zidovudine or stavudine or abacavir or tenofovir or didanosine)
Indinavir/ritonavir § ** + (lamivudine or emtricitabine) + (zidovudine or stavudine or abacavir or tenofovir or didanosine)
Lopinavir/ritonavir (co-formulated as Kaletra) + (lamivudine or emtricitabine) + (stavudine or abacavir or tenofovir or
didanosine)
Nelfinavir plus (lamivudine or emtricitabine) + (zidovudine or stavudine or abacavir or tenofovir or didanosine)
Saquinavir (hgc or sgc)/ritonavir § + (lamivudine or emtricitabine) + (zidovudine or stavudine or abacavir or tenofovir or
didanosine)
Triple NRTI Abacavir plus lamivudine + zidovudine (only when an NNRTI- or PI-based regimen cannot or should not be used)
Key to abbreviations: NNRTI = non-nucleoside reverse transcriptase inhibitor; PI = protease inhibitor; hgc = saquinavir hard-gel capsule (Invirase); sgc = saquinavir soft-gel capsule (Fortovase); NRTI = nucleoside
reverse transcriptase inhibitor.
† Efavirenz should be avoided in pregnant women and women of childbearing potential.
# Stavudine may cause a higher incidence of lipoatrophy, hyperlipidemia, and mitochondrial toxicities than other NRTIs.
§ Low-dose (100-400 mg) ritonavir. See Table 4 from the Adult Antiretroviral Guidelines (cited below) for doses used with specific PIs.
** Use of ritonavir with indinavir might increase the risk of renal adverse events.
Source: U.S. Department of Health and Human Services. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States.
Table 2. MMWR Recomm Rep. 2005 Jan 21;54(RR02);1-20. Available online at http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=11.