Public Health Service Guidelines for the Management of Possible Sexual, Injecting-Drug-Use, or Other Nonoccupational Exposure to HIV, Including Considerations Related to Antiretroviral Therapy

Commentary

Based on the knowledge of HIV pathogenesis and the possible benefit of antiretroviral agents in preventing transmission (demonstrated in animal and human studies), some physicians believe that antiretroviral agents are indicated for persons with possible sexual, injecting-drug-use, or other nonoccupational HIV exposure.⁽⁴⁾ However, PHS cannot definitively recommend for or against antiretroviral agents in these situations because of the lack of efficacy data on the use of antiretroviral agents in preventing HIV transmission after possible nonoccupational exposure. Efficacy and effectiveness data and additional epidemiologic information are needed, including the number of infections that could be averted by antiretroviral drugs, the number of persons who would need treatment to avert one infection, the effects of antiretroviral drug availability on risk behavior, and physician practices in prescribing antiretroviral drugs.

Antiretroviral agents should not be used for persons with HIV exposures that have a low risk of transmission (e.g., potentially infected body fluid on intact skin) or for persons who seek care too late for the anticipated interruption of transmission (>72 hours after reported exposure). Physicians considering the use of antiretroviral agents after a nonoccupational HIV exposure should recognize that benefits likely will be restricted to situations in which the risk for infection is high, the intervention can be initiated promptly, and adherence to the regimen is likely. In these instances, the physician and the patient should weigh the low per-act probability of HIV transmission associated with the reported exposure against the uncertain effectiveness, potential toxicities, and cost of antiretroviral drugs, as well as the patient's anticipated adherence to the therapy. If physicians decide to use antiretroviral agents, they should consult with an HIV-care provider experienced with their use.

Postexposure antiretroviral therapy should never be administered routinely or solely at the request of a patient. It is a complicated medical therapy, not a form of primary HIV prevention. It is not a "morning-after pill," but, if proven effective, can constitute a last effort to prevent HIV infection in patients for whom primary prevention has failed to protect them from possible exposure.