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

2–20 | Clinical Manual for Management of the HIV-Infected Adult/2006
If the HIV status of the source patient is unknown, a
rapid HIV test may help in determining the need for
PEP (see chapter Rapid Testing). Although a positive
rapid test requires confirmation before the individual
is diagnosed as HIV infected, for the purposes of PEP,
it should be considered a true positive until proven
otherwise, and the exposed worker should be counseled
accordingly. If, upon further testing, the source patient
is determined to be HIV uninfected, PEP can be
discontinued. A negative rapid test is considered reliable
unless the source reports recent high-risk HIV exposure
or symptoms of primary HIV (see chapter Primary
HIV Infection). If a rapid test is not available, PEP is
considered “generally not warranted” for exposures
involving source patients whose HIV status is unknown.
However, PEP can be considered if the source patient
has risk factors for HIV infection. PEP should not be
delayed (beyond 1-2 hours) while awaiting information
about the source patient. PEP is not recommended for
exposures to HIV-seronegative source patients.
If the source patient is known or suspected to
have infection with HIV that is resistant to ARV
medications, seek expert consultation in selecting an
appropriate PEP regimen. However, PEP should not be
delayed while consultation is obtained.
Additional alternative ARVs are included in the
USPHS guidelines, but certain ARVs are not
recommended for PEP, including abacavir, delavirdine,
nevirapine, and the combination of didanosine +
stavudine. Refer to the appendix in the updated USPHS
guidelines for a more complete discussion of the dosing,
advantages, and disadvantages of the various ARV
agents available for PEP.
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 PEP, including
the importance of protection against future HIV
exposures, timely initiation of PEP medications, and
adherence to these medications for 28 days. Counsel
exposed workers to use latex barriers with their sexual
partners until HIV infection has been ruled out.
Follow-Up
Exposed workers should be evaluated at 1 week for
review of all test results. For patients taking PEP,
adherence assessment and evaluation of any side effects
also should be included. At 2 weeks, blood testing (eg,
CBC, LFTs) should be done for patients on a 28-day
PEP regimen to monitor for PEP toxicity, as indicated
by the particular ARV regimen. PEP is discontinued at
4 weeks, and generally no laboratory studies should be
repeated unless there is a need to recheck an abnormal
result. Follow-up HIV antibody testing should be
done at 6 weeks, 3 months, and 6 months after the
exposure. In addition to health-education counseling,
some patients may need emotional support during their
follow-up visits.
Symptoms of primary HIV infection such as fever,
rash, and lymphadenopathy (see chapter Primary
HIV Infection) may occur in HCWs who have been
infected with HIV through occupational exposure.
Every exposed HCW should be counseled about the
symptoms of primary HIV infection and instructed to
return for reevaluation as soon as possible if symptoms
develop. If symptoms consistent with primary HIV
appear within 4-6 weeks after an occupational exposure,
the HCW should be evaluated immediately. If the
worker is found to be infected with HIV, he or she
should be referred immediately to an HIV specialist for
further evaluation and care.
Expert Consultation
For consultation on the treatment of occupational
exposures to HIV and other bloodborne pathogens,
the clinician managing the exposed patient can call
the National Clinicians’ Post-Exposure Prophylaxis
Hotline (PEPline) at 888-HIV-4911 (888-448-4911).
This service is available 24 hours a day, at no charge
(additional information on the Internet is available at
http://www.ucsf.edu/hivcntr). PEPline support may be
especially useful in challenging situations, such as when
drug-resistant HIV strains are suspected or the HCW
is pregnant.
Prophylaxis against HBV and HCV
Prophylaxis against hepatitis B is recommended for
patients with potential exposure to HBV who have not
been vaccinated against HBV. Give hepatitis B 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 surface antibody positive),
give HBIG at the time of the postexposure workup
and repeat in 1 month. For patients with immunity to
hepatitis B, no treatment is indicated.