Considerations in Caring for Persons
After Potential Nonoccupational Exposure
to HIV When Data Are Inadequate
Evaluation for STDs and Substance Abuse
Sexual activities associated with a risk for HIV transmission also are associated with risk for unintended pregnancy and STDs (e.g., syphilis, gonorrhea, chlamydia, or hepatitis B virus). Treatment for STDs should follow the CDC's 1998 Guidelines for Treatment of Sexually Transmitted Diseases,(49) and victims of sexual assault should receive additional evaluation and counseling. (50) Women at risk for unintended pregnancy should be offered emergency contraception.(51) Persons with possible HIV exposure through percutaneous routes from sharing syringes or needles should be assessed for hepatitis B and hepatitis C virus infections and considered for hepatitis B virus vaccination. They also should be assessed and referred for appropriate substance abuse treatment.
HIV Evaluation and Management
Persons who report possible nonoccupational HIV exposure should be evaluated
for sexual and injecting-drug-use behavior that might lead to recurrent exposure. In all situations, health-care providers should offer confidential risk-reduction counseling(52)
during initial and follow-up visits. Persons who have been sexually assaulted also can be referred for anonymous or confidential voluntary counseling and testing within 72 hours of exposure to establish their HIV status at the time of the assault. Some patients (e.g., those who have inconsistently or incorrectly used condoms or relapsed into injecting-drug use) will need to be referred for intensive risk-reduction interventions. Health-care providers evaluating persons for nonoccupational HIV exposure should know where such services are available and help patients obtain them promptly.
Persons with nonoccupational HIV exposures should receive medical evaluations,
including HIV-antibody tests at baseline and periodically for at least 6 months after exposure (e.g., at 4-6 weeks, 12 weeks, and 6 months). All persons evaluated for possible nonoccupational HIV exposure should be counseled to initiate or resume
protective behaviors to prevent additional exposure and to prevent possible secondary transmission if they become infected while receiving antiretroviral therapy.
Considerations in Initiating Antiretroviral Therapy
Physicians considering the initiation of antiretroviral therapy in an attempt to reduce the risk for HIV infection in an exposed person should take the following steps in consultation with an expert in the use of antiretroviral agents:
- Evaluate the HIV status and risk-behavior history of the reported source of HIV
- Provide medical care, supportive counseling, and prevention services to persons who are determined to be HIV-infected when they seek care for a potential HIV exposure.
- Evaluate the risk for HIV transmission (if there is convincing evidence of HIV infection in the reported source patient). Physicians should determine the specifics of the risk event (e.g., no condom, torn condom, whether receptive or insertive partner, injection before or after others, number of persons sharing injection equipment) and the presence or absence of factors that would modify risk (e.g., vaginal or anal tears or bleeding, visible genital ulcers or other evidence of an active STD, or bleach treatment of injection equipment).
- Determine the time elapsed between exposure and presentation for medical
care. Although animal studies indicate that antiretroviral agents are most effective within 1-2 hours of exposure and probably not effective when started later than 24-36 hours after exposure, the interval during which therapy can be beneficial for humans is unknown.
- Evaluate the frequency of HIV exposure. Uninfected persons who request
antiretroviral agents should be evaluated for sexual, injecting-drug-use, and other
behaviors that might lead to recurrent HIV exposures. Antiretroviral therapy is
not a replacement for adherence to behaviors that reduce the risk of HIV exposure.
- Provide counseling and obtain informed consent. Because postexposure
prophylaxis is an experimental therapy of unproven efficacy, informed consent should be obtained and recorded in the medical charts of all persons prescribed antiretroviral agents following nonoccupational exposure. Such consent should
document the patient's understanding of a) the need to initiate or resume relevant HIV risk-reduction behaviors (e.g., condom use and/or drug treatment); b) the limited knowledge about the effectiveness and toxicity of antiretroviral treatment
for nonoccupational exposure; c) the known side effects of the medications being prescribed; d) the name and phone number of a source for follow-up medical
care; e) the frequency and timing of recommended follow-up HIV testing;(1,2,52) f) the signs and symptoms associated with acute HIV seroconversion; and g) the need for adherence to prescribed medications to maximize efficacy and reduce the risk for infection with a drug-resistant variant. The patient should be told that physicians have diverse opinions about the use of antiretroviral medications to treat possible nonoccupational HIV exposure and that PHS cannot make definitive recommendations because of limited knowledge.
- Persons younger than age 16 years at the time of exposure should be evaluated (before therapy is initiated) by pediatricians, family physicians, or other clinicians expert in the specific medical needs, consent issues, and other factors involved in their treatment, including the use of antiretroviral medicines for children and adolescents. These factors can include the investigation of possible child sexual abuse, state-specific legal reporting requirements for situations that endanger the welfare of minors, and local definitions of emancipation or other consent requirements that define the circumstances under which children and adolescents can give legal consent for their own medical care.
- HIV-exposed women who are pregnant (or could become so as a consequence of
the exposure event) should be evaluated before antiretroviral therapy is initiated
in consultation with obstetricians or other physicians expert in the care of HIV
infection during pregnancy to define which antiretroviral agent(s) would be
appropriate to the health of the woman and the fetus. Women should be counseled
on a) the limited data available about the short-term safety for the fetus and the
long-term safety of in utero antiretroviral exposure for the infant; b) the theoretical risks of suggested antiretroviral agents to the fetus during specific gestational periods; and c) CDC's recommendations regarding antiretroviral therapy for HIV-infected pregnant women.(53,54) No studies have been conducted on the safety and effectiveness of antiretroviral agents in preventing HIV infection in uninfected women during attempts to conceive with HIV-infected partners, and this therapy is not recommended for such use.
- If antiretroviral therapy is used, drug-toxicity monitoring should include a complete blood count and renal and hepatic chemical function tests when therapy is
initiated and again 2 weeks after the patient begins to take the medications. If
subjective or objective toxicity is noted, physicians should consult with their
experts on the need for further diagnostic studies and dose reduction or drug
substitution. It is possible that antiretroviral therapy during early HIV infection
could benefit the patient by reducing the initial level of viral replication (i.e., the set point) and decreasing the extent of lymph node infiltration. Thus, for patients with the highest-risk exposures, health-care providers may consider continuing therapy until HIV test results are received from a specimen drawn after 28 days of treatment. Patients should be monitored for signs and symptoms of acute HIV infection during therapy. If such conditions develop, the patient should be tested for HIV (p24 antigen, HIV viral load assays) during their 4-week course of therapy with confirmation by standard HIV antibody tests. Persons who become infected while taking antiretroviral therapy should be advised to continue taking the medication pending transfer to a health-care provider who specializes in long-term HIV care.(55,56)
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