Health care personnel who are exposed to HIV in the workplace should immediately begin postexposure prophylaxis (PEP) with at least 3 antiretroviral drugs to prevent HIV infection, according to an updated guideline from the US Public Health Service (USPHS). The new guideline includes PEP regimens that reflect the availability of newer and better-tolerated antiretroviral agents than were previously available.
Although the new guideline’s overall approach to managing occupational exposure to HIV has not changed significantly since the USPHS released its 2005 guideline, the advice to use PEP regimens that combine 3 or more antiretrovirals for all occupational exposures is an important change from the strategy recommended in the earlier guideline. That approach involved the challenging task of assessing the risk of an individual exposure to help determine the number of drugs (2 vs 3 or more) given for PEP.
In addition, the drugs previously recommended for PEP were associated with a high frequency of adverse effects and drug-related toxicities that proved problematic. With this update, the preferred PEP regimen is now a combination of raltegravir and Truvada (tenofovir/emtricitabine). Among other benefits, improved tolerability can help increase the likelihood that health care workers who are being treated will actually complete the full regimen.
Health care workers who are taking PEP after occupational exposure should complete a full 4-week regimen and undergo follow-up HIV testing, close monitoring for drug toxicity, and counseling. Follow-up appointments should occur within 72 hours of the exposure, “especially as additional information about the exposure or source person becomes available,” the guideline advises. Although the authors include a detailed list of when to seek expert consultation (such as when the health care worker who was exposed to HIV already has a serious underlying illness), they also emphasize that this guidance should not be at the expense of delaying treatment.
The guideline also indicates that follow-up HIV testing of the treated person may be concluded at 4 months after exposure rather than at 6 months if a newer fourth-generation HIV antigen/antibody combination test (HIV p24 antigen and HIV antibody) is used. HIV testing of source patients (without delaying the initiation of PEP in the health care worker), using methods that provide rapid results, is also suggested.
The report continues to emphasize the importance of primary prevention strategies. “Preventing exposures should be the leading strategy to prevent occupational HIV infections,” said lead author David Kuhar, MD, in a statement. “However, when an exposure occurs, it should be considered an urgent medical concern and a PEP regimen should be started right away, ideally within hours of the potential exposure.”
In the event of an HIV exposure, expert consultation can be made with local occupational health experts or by calling the National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) at 1-888-448-4911.