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

P: Plan
Laboratory Testing
Provide pretest counseling and perform a baseline HIV
antibody test. Test for other infections transmitted
through occupational exposure, particularly hepatitis B
(HBV surface antigen, surface antibody, core antibody),
and hepatitis C (HCV antibody). Obtain complete
blood count (CBC), chemistry panel, and liver function
tests (LFTs) at baseline, before treatment with ARV
medications. For women who may be pregnant, perform
a pregnancy test.
Treatment
Consult Table 1 or Table 2 to determine whether
the worker should be offered PEP medications. For
occupational exposures to infectious body fluids from
an HIV-infected source patient, the USPHS guidelines
state that PEP should be recommended or considered,
Table 3. Antiretroviral Options for Occupational Postexposure Prophylaxis of HIV Infection
Basic 2-NRTI Regimens
Preferred
• Zidovudine 300 mg + lamivudine 150 mg twice daily (available as
Combivir, 1 tablet twice daily)
• Zidovudine 300 mg twice daily + emtricitabine 200 mg once daily
Expanded Regimens (one of the following may be added to a basic regimen)
Protease Inhibitors
Preferred
• Lopinavir/ritonavir combination 400/100 mg twice daily
Alternative
• Atazanavir 300 mg once daily + ritonavir 100 mg once daily
• Atazanavir 400 mg once daily*
NNRTI Regimen
• Efavirenz 600 mg once daily (not recommended in pregnant women)
Section 2—Health Maintenance and Disease Prevention | 2–19
depending on the assessed risk. The assessed risk also
helps to determine whether a “basic” 2-drug regimen or
“expanded” >3-drug regimen should be selected. Other
considerations in choosing the medications for a PEP
regimen include:
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The likelihood that the source patient’s virus is
resistant to ARV medication(s)
Possible drug toxicities for the exposed HCW
Drug-drug interactions with other medications the
HCW may be taking
If the HCW is a candidate for PEP, counsel him or
her about the potential risks and benefits of PEP. If
the worker elects to start therapy, consider potential
regimens (Table 3). Select a regimen that is likely
to be effective but tolerable; consider the potential
adverse effects of ARVs. Note that certain ARV agents,
including nevirapine, should not be used for PEP.
Efavirenz should be avoided in pregnant women.
• Tenofovir 300 mg once daily + lamivudine 300 mg once daily
• Tenofovir 300 mg once daily + emtricitabine 200 mg once daily
(available as Truvada, 1 tablet once daily)
• Fosamprenavir 1,400 mg twice daily
• Fosamprenavir 700 mg twice daily + ritonavir 100 mg twice daily
Key to abbreviations: NRTI = nucleoside analogue reverse transcriptase inhibitor; NNRTI = nonnucleoside reverse transcriptase inhibitor.
* Atazanavir cannot be used as a sole protease inhibitor if it is coadministered with tenofovir (use atazanavir + ritonavir).
Adapted from: Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis.
MMWR Recomm Rep. 2005 Sep 30; 54(RR09); 1-24. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=10.