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HEPPigram: Recommendations for HIV Post-Exposure Prophylaxis (PEP)

November 2001

Accidental exposure to HIV exists in the health care setting and provides a possible avenue for HIV transmission. Like sexual exposure, this mode of exposure is often preventable,1 but if it does occur, initiating post-exposure prophylaxis soon (within 1-2 hours optimally) after exposure provides the best defense against HIV transmission.2 The overall HIV transmission rate for cases of occupational exposure is estimated at approximately 0.3%.3 Exposure to blood and body fluids or tissues contaminated with blood carry a risk of transmission as do genital secretions. The risk of transmission for nonbloody body fluids (e.g., cerebrospinal, pericardial, amniotic) is undetermined. Exposure to nonbloody tears, sweat, saliva, urine, vomit, or feces is not considered to pose a significant risk of HIV transmission.2

The rationale behind PEP is that it appears to stop cellular HIV infection before the virus becomes established in cells. In order for PEP to be effective, then, it must be initiated before there is detectable viremia.3 The following two tables provide guidelines for provided PEP in an occupational setting. Most often, the basic two-drug PEP regimen is the combination of zidovudine plus lamivudine, although other combinations may be considered.2 The expanded three-drug PEP recommendation adds a PI (lopinavir), an NRTI (abacavir), or an NNRTI (efavirenz) to the basic regimen.2 An occupational exposure report should also accompany each incident (Table 2).


Table 1: HIV PEP for Percutaneous Injuries2
Infection Status of Source
Exposure TypeHIV+ Class 11HIV+ Class 21Source of Unknown HIV Status2Unknown Source3HIV Negative
Less Severe4Recommend Basic 2-Drug PEPRecommend Expanded 3-Drug PEPGenerally, no PEP warranted, however, consider basic 2-drug PEP5 for source with HIV risk factors6Generally, no PEP warranted, however, consider basic 2-drug PEP5 in settings where exposure to HIV-infected persons is likelyNo PEP warranted
More Severe7Recommend Expanded 3-Drug PEPRecommend Expanded 3-Drug PEPGenerally, no PEP warranted, however, consider basic 2-drug PEP5 for source with HIV risk factors6Generally, no PEP warranted, however, consider basic 2-drug PEP5 in settings where exposure to HIV-infected persons is likelyNo PEP warranted
  1. HIV-positive, Class 1 -- asymptomatic HIV infection or known low viral load (e.g., <1,500 RNA copies/mL). HIV-positive, Class 2 -- symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation, initiation of post-exposure prophylaxis (PEP) should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures.

  2. Source of unknown HIV status (e.g., deceased source person with no sample available for HIV testing).

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  3. Unknown source (e.g., a needle from a sharps disposal container).

  4. Less severe (e.g., solid needle or superficial injury).

  5. The designation "consider PEP" indicates PEP is optional and should be based on an individualized decision between the exposed person and the treating clinician.

  6. If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.

  7. More severe (e.g., large-bore needle, deep puncture, visible blood on device, or needle used in patient's artery or vein).

For information on mucous membrane and non-impact skin exposures see the CDC Guidelines.

Note: Some State Departments of Health, including New York, recommend 3-drug PEP whenever PEP in indicated.


Table 2: Information for Occupational Exposure Report2
  • Date and time of exposure.

  • Details of where and how exposure occurred, including the procedure being performed at time of exposure.

  • Details of severity of exposure (amount, type of exposure, depth of injury, etc.).

  • Details of exposure source.

  • Details of exposed person (i.e., HBV vaccination status).

  • Details of PEP, counseling, and follow-up: counseling and follow up should always be offered to address psychological effects of occupational exposure.


Table 3: Situations Requiring Expert* Consultation for PEP2
  • Delayed (more than 24-36 hours) exposure report.

  • Unknown source.

  • Pregnancy (known or suspected) in exposed person.

  • Antiretroviral resistance of source virus.

  • Toxicity of initial PEP regimen.

* Expert: Local expert or the National Clinician's PEP Hotline (PEPline: 1.888.448.4911).


References

  1. Proia L.A., Kessler H.A. 2001 Infect Med 18 (9): 428-438. Also available at http://hiv.medscape.com.

  2. Centers for Disease Control and Prevention. MMWR 2001;50 (No. RR-11).

  3. Nwokolo N., Hawkins D.A. The AIDS Reader 2001 Aug.; 8 (11):402-12.

  4. HEPP News Post-Exposure Prophylaxis Issue, Feb. 1999. Available on the Web at http://www.hivcorrections.org/archives/feb99/february.PDF.


Back to the HEPP News November 2001 contents page.



  
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This article was provided by Brown Medical School. It is a part of the publication HEPP News.
 
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