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Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis
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US Public Health Service Guideline
Received June 27, 2013; accepted June 27, 2013; electronically published August 6, 2013
Link to published Guidelines: http://www.jstor.org/stable/10.1086/672271
David T. Kuhar, MD,1 David K. Henderson, MD,2 Kimberly A. Struble, PharmD,3 Walid Heneine, PhD,4 Vasavi Thomas, RPh, MPH,4 Laura W. Cheever, MD, ScM,5 Ahmed Gomaa, MD, ScD, MSPH,6 Adelisa L. Panlilio, MD,1 and US Public Health Service Working Group
"The PHS now recommends emtricitabine (FTC) plus TDF (these 2 agents may be dispensed as Truvada, a fixed-dose combination tablet) plus raltegravir (RAL) as HIV PEP for occupational exposures to HIV. This regimen is tolerable, potent, and conveniently administered, and it has been associated with minimal drug interactions. Additionally, although we have only limited data on the safety of RAL during pregnancy, this regimen could be administered to pregnant HCP as PEP (see the discussion above). Preparation of this PEP regimen in single-dose "starter packets," which are kept on hand at sites expected to manage occupational exposures to HIV, may facilitate timely initiation of PEP......
.....Several drugs may be used as alternatives to FTC plus TDF plus RAL. TDF has been associated with renal toxicity,69 and an alternative should be sought for HCP who have underlying renal disease. Zidovudine could be used as an alternative to TDF and could be conveniently prescribed in combination with lamivudine, to replace both TDF and FTC, as Combivir. Alternatives to RAL include darunavir plus ritonavir (RTV), etravirine, rilpivirine, atazanavir plus RTV, and lopinivir plus RTV. When a more cost-efficient alternative to RAL is required, saquinivir plus RTV could be considered. A list of preferred alternative PEP regimens is provided in Appendix A." see Table 1a below
This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1; (6) close follow-up for exposed personnel (Box 2) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) 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 (Box 2); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.
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