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New York state - UPDATE: HIV Prophylaxis Following Occupational Exposure
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The Office of the Medical Director, New York State Department of Health AIDS Institute, is pleased to announce that the Medical Care Criteria Committee, under the leadership of Judith Aberg, MD and Samuel Merrick, MD, has posted updated guidelines for HIV Prophylaxis Following Non-Occupational Exposure (nPEP) and HIV Prophylaxis for Victims of Sexual Assault.
http://www.hivguidelines.org/clinical-guidelines/post-exposure-prophylaxis/hiv-prophylaxis-following-occupational-exposure/?utm_source=HIV Prophylaxis Following Non-Occupational Exposure and Sexual Assault&utm_campaign=nPEP and Sexual Assault&utm_medium=email
The Medical Care Criteria Committee now recommends tenofovir + emtricitabine* plus raltegravir as the preferred initial PEP regimen because of its excellent tolerability, proven potency in established HIV infection, and ease of administration. Zidovudine is no longer recommended in the preferred PEP regimen because it is believed to have no clear advantage in efficacy over tenofovir while having significantly higher rates of treatment-limiting side effects.
Occupational exposures require urgent medical evaluation. In this update, the Committee further emphasizes recommendations regarding the importance of initiating occupational PEP as soon as possible, ideally within 2 hours of exposure. A first dose of PEP should be offered while evaluation is underway. PEP should not be delayed while awaiting information about the source patient or results of the exposed worker's baseline HIV test.
The purpose of these guidelines is to provide recommendations for prescribing HIV post-exposure prophylaxis (PEP) following occupational exposure. To develop these guidelines, the New York State Department of Health AIDS Institute's (NYSDOH AI) Medical Care Criteria Committee has reviewed available literature addressing the biologic efficacy, effectiveness, and implementation of PEP, as well as current standards for the use of antiretroviral therapy (ART) in established HIV infection.
What's New -- 2013: The Preferred nPEP Regimen
The new preferred initial nPEP regimen for non-occupational exposures, including sexual assault, is tenofovir + emtricitabine* plus raltegravir (see Table 3) because of its excellent tolerability, proven potency in established HIV infection, and ease of administration. Zidovudine is no longer recommended in the preferred nPEP regimen because it is believed to have no clear advantage in efficacy over tenofovir while having significantly higher rates of treatment-limiting side effects.
* Lamivudine may be substituted for emtricitabine.
Appendix D provides payment options for PEP following non-occupational exposures, including sexual assault.
PEP for Sexual Assault Victims
New York State Public Health Law, Chapter 39, Section 2805-i requires hospitals providing treatment to victims of sexual assault to have 7-day starter packsof medication available on-site for rapid initiation of PEP following sexual assault. Arrangements should be made to ensure that the patient receives a continued supply of medication and an appointment is made with a clinician experienced in HIV PEP.
Types of Exposure That Warrant nPEP
Table 1 has been updated to more clearly delineate types of exposure that should prompt consideration of nPEP and those that do not warrant nPEP. Appendix B shows both the risk of HIV transmission for various HIV exposures as well as factors that may increase transmission risk.
HIV Testing of the Source Person
If the source person's rapid HIV test result is negative but there has been a risk for HIV exposure in the previous 6 weeks, plasma HIV RNA testing of the source person is also recommended. In this situation, nPEP should be initiated and continued until results of the plasma HIV RNA assay are available.
In most cases of sexual assault, the HIV status of the alleged assailant will not be known. New York State Criminal Procedure Law 210.16 requires testing of criminal defendants indicted for certain felony sex offenses for HIV, upon the request of the victim. For guidance on defendant testing, please visit NYS Court-Ordered HIV Testing of Defendants.
Persons with Ongoing High-Risk Behavior
A recommendation has been added that, after completion of the 28-day nPEP regimen, initiation of pre-exposure prophylaxis should be discussed for persons with ongoing high-risk behavior or who present for repeat courses of nPEP.
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