Clinical Manual for Management of the HIV-Infected ... - myCME.com

Once the decision is made to institute nPEP, do the
following:
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Begin ARV prophylaxis as soon as possible after the
exposure, but always within 72 hours. Treatment
should be continued for 28 days.
Provide counseling about the efficacy of nPEP,
including the importance of protection against
future HIV exposures, timely initiation of nPEP
medications, and adherence to these medications
for 28 days. Continued counseling about HIV risk
reduction may be appropriate. In cases of sexual
assault, refer the patient to a rape counselor.
Follow-Up
Patients should be evaluated at 1 week for review of all
test results and further risk reduction counseling. For
patients taking nPEP, this follow-up should include
adherence assessment and evaluation of any adverse
effects. A 2-week blood screening (CBC, LFTs, and
chemistry panel) should be done for patients on the
28-day nPEP regimen to monitor for nPEP toxicity.
Follow-up testing for HIV antibody in patients with
a negative baseline HIV antibody test should be
done at 6 weeks, 3 months, and 6 months after the
exposure. Some patients may also need health education
counseling and emotional support during their followup
visits. If patients develop acute HIV infection or are
discovered to be HIV seropositive at follow-up testing,
refer to an HIV specialist for evaluation and care (see
chapter Primary HIV Infection).
Prophylaxis against HBV and HCV
Prophylaxis against HBV is recommended for patients
with potential exposure to HBV who have not been
vaccinated against HBV. Give HBV immune globulin
(HBIG) as a 0.06 mL/kg intramuscular injection and
initiate the vaccination series. For patients who received
the vaccine series but did not develop protective
antibody (HBV sAb+), give HBIG at the time of
the postexposure workup and repeat in 1 month. For
patients with immunity to HBV (HBV sAb+), no
treatment is indicated.
For HCV, no recommended prophylactic treatments
are available. After potential exposure, check a baseline
HCV antibody test. If the source is known to have
HCV infection, consider alanine aminotransferase
(ALT) and HCV viral load testing at 4-6 weeks. HCV
antibody testing should be repeated at 4-6 months.
Section 2—Health Maintenance and Disease Prevention | 2–15
If HCV seroconversion occurs (indicated by ALT
elevation, detectable HCV viral load, or confirmed
positive HCV antibody test), refer the patient to a
hepatologist because early treatment of acute HCV may
be indicated.
Patient Education
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Patients should contact a medical provider or go
to an emergency room as soon as possible after a
potential HIV exposure has occurred. PEP may be
effective if it is started within 72 hours of exposure,
but the sooner medications are initiated, the better
the chance for preventing HIV transmission.
PEP medications should be taken as directed for
the full 28 days. Adherence to PEP medications is
essential for successful treatment.
If patients are experiencing uncomfortable adverse
effects, they should contact their providers. Providers
may prescribe medications to alleviate the adverse
effects or select other PEP medications.
The most effective way to prevent HIV infection is
to prevent exposure to HIV by practicing safer sex
and safer IDU techniques. Using condoms and not
sharing needles are successful preventive measures.
It is crucial to the success of PEP treatment that
patients not engage in risky sexual or needle-use
behaviors. If patients have questions about access to
condoms or clean needles, they should contact their
health care providers for assistance.
References
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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. MMWR Recomm Rep.
2005 Jan 21;54(RR02);1-20. Available online at
http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.
aspx?GuidelineID=11. Accessed May 19, 2006
U.S. Department of Health and Human Services.
Updated U.S. Public Health Service Guidelines
for the Management of Occupational Exposures to
HBV, HCV, and HIV and Recommendations for
Postexposure Prophylaxis. MMWR Recomm Rep.
2001 Jun 29;50(RR11). Available online at http://
aidsinfo.nih.gov/Guidelines/GuidelineDetail.
aspx?GuidelineID=10. Accessed May 19, 2006.