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==Background==
==Background==
*Probability of HIV transmission from a percutaneous needle stick is approximately 0.3% (1 in 300) and 0.09% from mucous membrane exposure.<ref>Marcus R. et al. CDC Cooperative Needlestick Surveillance Group. "Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus". N Engl J Med. 1988. 319: 1118–1123.</ref><ref>Bell D.M. "Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview". Am J Med. 1997. 102: 9–15.</ref>
*Also known as HIV Post-Exposure Prophylaxis (PEP)
*Also known as HIV Post-Exposure Prophylaxis (PEP)
*Probability of HIV transmission from a percutaneous needle stick is approximately 0.3% (1 in 300) and 0.09% from mucous membrane exposure.<ref>Marcus R. et al. CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med. 1988. 319: 1118–1123.</ref><ref>Bell D.M. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997. 102: 9–15.</ref>
*~79% transmission reduction
*~79% transmission reduction
*Common side-effects = constitutional, gastrointestinal
===Timing and Duration of PEP<ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>===
*Initiate ASAP (goal = <2 hours after exposure)
*Initiate ASAP (goal = <2 hours after exposure)
*>36 hours: normally deferred, unless particularly high risk
*Initiate if <72 hours since exposure
*Common side-effects = constitutional, gastrointestinal
*PEP is likely to be less effective when started more than 72 hours after exposure, but the interval after which no benefit is gained from PEP for humans is undefined.
*If initiation is delayed, the likelihood increases that benefits might not outweigh the risks inherent in taking antiretroviral medications.
 
===CDC recommendations===
From 2013 recommendations <ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>
*PEP is recommended when occupational exposures to HIV occur
*PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and continued for 28 days
*'''New recommendation''' - PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
*'''New recommendation''' - if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure; if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.


===National Clinician's Post-Exposure Prophylaxis Hotline===
===National Clinician's Post-Exposure Prophylaxis Hotline===
*1-888-448-4911, call for expert advice
*1-888-448-4911, call for expert advice


==Exposure Transmission Risk==
==Evaluation of Transmission Risk==
===Exposure Transmission Risk===
{| class="wikitable"
{| class="wikitable"
|-
|-
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===High Risk Exposures===
===High Risk Exposures===
'''Source'''
'''Source'''
#Symptomatic HIV/AIDS
*Symptomatic HIV/AIDS
#Acute seroconversion
*Acute seroconversion
#High viral load
*High viral load


'''Exposure'''
'''Exposure'''
#Deep injuries
*Deep injuries
#Visible blood on device
*Visible blood on device
#Injuries sustained placing a catheter in a vein/artery
*Injuries sustained placing a catheter in a vein/artery


===Low Risk Exposures===
===Low Risk Exposures===
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*Human Bites
*Human Bites


==Workup (Before Giving)==
==Workup==
===Source-Patient===
*Rapid HIV Test
**HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP<ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>''
 
===Exposed-Patient===
Only if giving PEP (before initiation):
*CBC
*CBC
*C7
*Chem 7
*LFTs
*LFTs
*Pregnancy test
*Pregnancy test


==Management==
==Management==
===Percutaneous Injuries===
====Superficial wound or solid needle====
*If HIV+ source asymptomatic or if viral load <15000 RNA/mL give basic regimen
*If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
*If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)
====Deep wound or hollow needle====
*If HIV+ source asymptomatic or if viral load <15000 RNA/mL give expanded regimen
*If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
*If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)
===Mucous Membrane Exposure===
====Small volume (few drops)====
*If HIV+ source asymptomatic or if viral load <15000 RNA/mL consider basic regimen
*If HIV+ with AIDS, acute seroconversion or high viral load give basic regimen
*If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)
====Large volume (splash)====
*If HIV+ source asymptomatic or if viral load <15000 RNA/mL give basic regimen
*If HIV+ with AIDS, acute seroconversion or high viral load give expanded regimen
*If HIV status unknown then no PEP (consider PEP if possible HIV risk from source)
==Treatment Regimens==
===2 drug Basic<ref name="NEJM">Landovitz RJ, Currier JS. Postexposure prophylaxis for HIV infection. N Eng J Med. 2009 Oct 29; 361(18): 1768-75. [http://www.uphs.upenn.edu/ppmc_emergency/PPMC%20Bookmarks/2012%20LLSA%20Articles/Postexposure%20Prophylaxis%20for%20HIV.pdf PDF]</ref>===
*Tenofovir-Emtricitabine (Truvada) one tablet (300 mg of tenofovir with 200 mg of emtricitabine) once daily OR
*Zidovudine–lamivudine (Combivir) one tablet (300 mg of zidovudine with 150 mg of lamivudine) twice daily
**this regimen is preferred in pregancy
===3 drug Expanded<ref name="NEJM"></ref>===
*Ritonavir–lopinavir (Kaletra) PLUS either tenofovir–emtricitabine or zidovudine–lamivudine)
**Two tablets (50 mg of ritonavir with 200 mg of lopinavir per tablet) twice daily, or four tablets once daily
*Ritonavir plus atazanavir (plus either tenofovir–emtricitabine or zidovudine–lamivudine
**100 mg of ritonavir plus 300 mg of atazanavir once daily
*Ritonavir plus darunavir (plus either tenofovir–emtricitabine or zidovudine–lamivudine)
**100 mg of ritonavir plus two tablets, each containing 400 mg of darunavir, once daily
==CDC recommendations==
''From 2013 recommendations <ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>''
#PEP is recommended when occupational exposures to HIV occur
#HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP
#PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and continued for a 4-week duration
#'''New recommendation''' - PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
#Expert consultation is recommended for any occupational exposures to HIV a
#Close follow-up for exposed personnel should be provided that includes
##Counseling
##Baseline and follow-up HIV testing
##Monitoring for drug toxicity
##Follow-up appointments should begin within 72 hours of an HIV exposure
#'''New recommendation''' - if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure; if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.
===Negligible Risk===
===Negligible Risk===
*NOT recommended
*NOT recommended


===Substantial Risk===
===Substantial Risk===
*CDC preferred regimen for '''28 days''':^<ref>Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.  August 6, 2013. http://www.jstor.org/stable/10.1086/672271 DOI: 10.1086/672271 </ref>
{{HIV post-exposure prophylaxis regimens}}
**Raltegravir (isentress) 400 mg PO twice daily, plus
**Truvada (tenofovir 300 mg + emtricitabine 200 mg) 1 PO once daily
*If known source patient with resistant HIV strain, consult HIV service for source-patient-specific PEP


^Consider interactions with current medication interactions and contraindications, such as renal impairment with Truvada
===Pregnant Patients===
*"Expert consultation should be sought in all cases"<ref>Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271</ref>


===Pregnant Patients===
==Disposition==
*Same as above
*Outpatient, with close follow-up for exposed persons that includes:<ref>Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.</ref>''
**Counseling
**Baseline and follow-up HIV testing
**Monitoring for drug toxicity
**Follow-up appointments should begin within 72 hours of an HIV exposure


==See Also==
==See Also==
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*[[Sexual assault]]
*[[Sexual assault]]
*[[Hepatitis B]]
*[[Hepatitis B]]
*[[HIV testing (in California)]]
*[[Harbor:Occupational exposure]]
**[[Harbor:Occupational exposure (dot-phrases)]]
==External Links==
*Harbor-UCLA Policy: https://wikem.org/wiki/File:Non-occupational_Post-Exposure_Prophylaxis_(nPEP)_for_HIV_Prevention_in_Adults_and_Adolescents_Expected_Practice.pdf
*http://ph.lacounty.gov/dhsp/prep-pep-actionkit.htm
*[https://www.cdc.gov/hiv/risk/pep/index.html CDC: Post-Exposure Prophylaxis]
*http://getprepla.com/


==Source==
==References==
<references/>
<references/>


[[Category:ID]]
[[Category:ID]]

Revisión actual - 21:05 7 jun 2022

Background

  • Also known as HIV Post-Exposure Prophylaxis (PEP)
  • Probability of HIV transmission from a percutaneous needle stick is approximately 0.3% (1 in 300) and 0.09% from mucous membrane exposure.[1][2]
  • ~79% transmission reduction
  • Common side-effects = constitutional, gastrointestinal

Timing and Duration of PEP[3]

  • Initiate ASAP (goal = <2 hours after exposure)
  • Initiate if <72 hours since exposure
  • PEP is likely to be less effective when started more than 72 hours after exposure, but the interval after which no benefit is gained from PEP for humans is undefined.
  • If initiation is delayed, the likelihood increases that benefits might not outweigh the risks inherent in taking antiretroviral medications.

CDC recommendations

From 2013 recommendations [4]

  • PEP is recommended when occupational exposures to HIV occur
  • PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and continued for 28 days
  • New recommendation - PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV
  • New recommendation - if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure; if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

National Clinician's Post-Exposure Prophylaxis Hotline

  • 1-888-448-4911, call for expert advice

Evaluation of Transmission Risk

Exposure Transmission Risk

Exposure^
 Risk
Percutaneous 0.3%
Mucocutaneous 0.09%
Needle-sharing injection drug 0.7%
Receptive anal intercourse 0.5%
Receptive penile-vaginal intercourse 0.1%
Insertive anal intercourse 0.07%
Insertive penile-vaginal intercourse 0.05%
Receptive oral (male) intercourse 0.01%
Insertive oral (male) intercourse 0.005%

^assumes no condom use

High Risk Exposures

Source

  • Symptomatic HIV/AIDS
  • Acute seroconversion
  • High viral load

Exposure

  • Deep injuries
  • Visible blood on device
  • Injuries sustained placing a catheter in a vein/artery

Low Risk Exposures

  • Dried blood on an old needle
  • Human Bites

Workup

Source-Patient

  • Rapid HIV Test
    • HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP[5]

Exposed-Patient

Only if giving PEP (before initiation):

  • CBC
  • Chem 7
  • LFTs
  • Pregnancy test

Management

Negligible Risk

  • NOT recommended

Substantial Risk

Preferred HIV PEP Regimen[6][7]

PEP should be started as soon as possible after significant exposure and continued for 28 days[8]

  • Raltegravir (Isentress; RAL) 400 mg PO twice daily, plus
  • Truvada, 1 PO once daily (Tenofovir DF [Viread; TDF] 300 mg emtricitabine [Emtriva; FTC] 200 mg)

Other Considerations

  • If known source patient with resistant HIV strain, consult HIV service for source-patient-specific PEP
  • Consider interactions with current medication interactions and contraindications, such as renal impairment with Truvada
    • For patients with creatinine clearance <60mL/min, consider Raltegravir 400mg PO twice daily, plus Zidovudine and Lamivudine with doses adjusted to the degree of renal dysfunction.[9]
  • If the source exposure does report exposure to HIV within the last 6 weeks, HIV RNA PCR (HIV viral load) should be sent along with HIV Ag/Ab screen on the source and nPEP should be initiated for the exposed patient
    • If both tests result not detected and nonreactive, respectively, nPEP should be discontinued.
    • If the source is willing and able to be tested and is found to be HIV-negative with no recent high-risk exposures to HIV, nPEP is not indicated and should not be initiated, or discontinued if already started.
    • The exposed patient still warrants baseline HIV testing and should be offered baseline and follow-up testing for other transmissible infections, e.g. hepatitis A, B, and C, syphilis, chlamydia, and gonorrhea.

Pregnant Patients

  • "Expert consultation should be sought in all cases"[10]

Disposition

  • Outpatient, with close follow-up for exposed persons that includes:[11]
    • Counseling
    • Baseline and follow-up HIV testing
    • Monitoring for drug toxicity
    • Follow-up appointments should begin within 72 hours of an HIV exposure

See Also

External Links

References

  1. ↑ Marcus R. et al. CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus. N Engl J Med. 1988. 319: 1118–1123.
  2. ↑ Bell D.M. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997. 102: 9–15.
  3. ↑ Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  4. ↑ Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  5. ↑ Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  6. ↑ Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271
  7. ↑ Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services
  8. ↑ Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
  9. ↑ Dominguez KL et al. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV--United States, 2016. Available at: https://stacks.cdc.gov/view/cdc/38856
  10. ↑ Kuhar D, et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. September 2013. 34(9):875-892. DOI: 10.1086/672271. http://www.jstor.org/stable/10.1086/672271
  11. ↑ Kuhar DT et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. doi: 10.1086/672271.
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