_______________________________________________________________________ HIV/AIDS: An Update
Postexposure Prophylaxis The U.S. Public Health Service (PHS) provides guidance for managing healthcare personnel who have occupational exposure to blood and/or other bodily fluids from a person suspected or known to have HIV infection [39]. Because most occupational HIV exposures do not result in transmission of HIV, potential toxicity should be carefully considered when prescribing postexposure prophylaxis (PEP). The 2013 updated guidelines for occupational PEP focused on tolerability, side effects, toxicity, safety in pregnancy and lactation, pill burden, and frequency of dosing to maximize adherence to a PEP regi- men. Although the principles of exposure management remain unchanged, recommended PEP regimens and the duration of follow-up HIV testing for exposed personnel were updated in 2018 [39]. When possible, these recommendations should be implemented in consultation with persons having expertise in antiretroviral therapy and HIV transmission, due to the complexity of selecting appropriate treatment. The 2018 updated PHS guidelines recommend initiating PEP medication as soon as possible after occupational exposure to HIV and continuation of the regimen for four weeks. PEP regimens should contain three (or more) antiretroviral drugs for all occupational exposures to HIV [39]. Examples of rec- ommended PEP regimens include those consisting of a dual nucleoside reverse transcriptase inhibitor (NRTI) backbone plus an integrase strand transfer inhibitor (INSTI), protease inhibitor (PI) (boosted with ritonavir), or non-nucleoside reverse transcriptase inhibitor (NNRTI). The PHS preferred regimen for management of most healthcare professionals’ exposures to HIV is raltegravir 400 mg twice daily plus Tru- vada (combination emtricitabine 200 mg and tenofovir 300 mg) once daily, [39]. This preparation is available as a starter packet that should be stocked at every healthcare facility where exposure to HIV is possible. As discussed, the regimen has been selected for its tolerability and safety profile. There are several alternative regimens that may be selected due to individual patient concerns. For example, tenofovir is associated with renal toxicity, and an alternative NRTI/NNRTI pair, such as zidovudine plus lamivudine (available as Combivir), would be selected for patients with renal disease [39]. Healthcare professionals with occupational exposure to HIV should receive close follow-up to assure counseling, baseline and follow-up HIV testing, and medical evaluation regardless of whether they receive PEP. The 2018 PHS guideline highlights the importance of follow-up within 72 hours of an HIV expo- sure to allow the initial shock to fade and to provide greater opportunity for full understanding of the risks and benefits of PEP; confirmation testing to ensure the necessity of PEP; increase adherence to PEP; monitoring for adverse reactions and side effects; and treating comorbidities and altering the regimen [39]. This window provides an opportunity to dis- cuss the importance of preventing secondary transmission of HIV in the 6 to 12 weeks following initial infection. If a newer fourth-generation HIV p24 antigen-HIV antibody test is utilized for follow-up, then HIV-antibody testing may be
concluded at four months after exposure. If a newer testing platform is not available, follow-up HIV testing should be performed for a six-month postexposure period (e.g., at 6 weeks, 12 weeks, and 6 months) [39]. It is unclear whether an extended follow-up period (e.g., 12 months) is indicated for individuals not coinfected with hepatitis C and HIV. If PEP is used, drug-toxicity monitoring should be performed at baseline and again two weeks after starting PEP. Clinical judgment, based on medical conditions that may exist in pre-exposure and/or as a result of the regimen, should determine the scope of testing. If the source patient is found to be HIV negative, PEP should be discontinued immediately [39]. Nonoccupational Postexposure Prophylaxis (nPEP) In 2016, the CDC published updated guidelines for the recommenda- tion of PEP for nonoccupational exposures. This section is taken from Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016 [40]. Healthcare providers should evaluate persons rapidly for nPEP when care is sought within 72 hours after a potential nonoccupational exposure that presents a substantial risk for HIV acquisition. All persons considered for nPEP should have determination of their HIV infection status by HIV testing, preferably by using rapid combined Ag/Ab, or antibody blood tests. If rapid HIV blood test results are unavailable, and nPEP is otherwise indicated, it should be initiated without delay and can be discontinued if the patient is later determined to have HIV infection already or the source is determined not to have HIV infection. nPEP is recommended when the source of the body fluids is known to be HIV-positive and the reported exposure presents a substantial risk for transmission. nPEP is not recommended when the reported exposure presents no substantial risk of HIV transmission or when care is sought more than 72 hours after potential exposure. A case-by-case determination about the nPEP is recommended when the HIV infection status of the source of the body fluids is unknown and the reported exposure presents a substantial risk for transmis- sion if the source did have HIV infection. Healthcare providers should evaluate persons rapidly for nPEP when care is sought within 72 hours after a potential nonoccupational exposure that presents a substantial risk for HIV acquisition. All persons considered for nPEP should have determination of their HIV infection status by HIV testing, preferably by using rapid combined Ag/Ab, or antibody blood tests. If rapid HIV blood test results are unavailable, and nPEP is otherwise indicated, it should be initiated without delay and can be discontinued if the patient is later determined to have HIV infection already or the source is determined not to have HIV infection. nPEP is recommended when the source of the body fluids is known to be HIV-positive and the reported exposure presents a substantial risk for transmission. nPEP is not recommended when the reported exposure presents no substantial risk of HIV transmission or when care is sought more than 72 hours after potential exposure. A case-by-case
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MDCT2026
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