HIV Prophylaxis Following Non-occupational Exposure
HIV Prophylaxis Following Non-occupational Exposure
Recommendations:
• All patients receiving PEP should be re-evaluated within 3 days of the exposure to further clarify the nature of the exposure, review available source person data, evaluate adherence, and monitor toxicities associated with the PEP regimen. (AIII)
• The exposed person should be evaluated weekly while receiving PEP to assess treatment adherence, side effects of treatment, interval physical complaints, and emotional status. (AIII) Longitudinal care of the exposed person during PEP treatment and the follow-up period should be provided by or in consultation with a clinician experienced in managing nPEP. Emergency Departments and urgent care centers should establish linkages with local HIV providers to facilitate easy referral of patients for follow-up care. Providers who do not have access to a clinician experienced in PEP should use the National Clinicians' Consultation Center PEPline at 1-888-HIV-4911 (1-888-448-4911) for phone consultation. When using the PEPline, providers from New York State should identify themselves as practicing in the State.
• Clinicians should provide risk-reduction counseling to exposed persons to prevent secondary transmission during the 12-week follow-up period. HIV-exposed individuals should be advised to:
– use condoms to prevent potential sexual transmission (AI)
– avoid pregnancy and breastfeeding (AI)
– avoid needle-sharing (AI)
– refrain from donating blood, plasma, organs, tissue, or semen (AI)
During the PEP treatment period, other blood tests may be indicated to monitor for side effects of treatment. The timing and specific testing indicated varies based on the PEP regimen used (see Table 7).
Clinicians should be aware of the resources within the community that offer medical and supportive counseling/adherence services needed following non-occupational exposure.
Table 7. Monitoring Recommendations After Initiation of PEP Regimens Following Non-occupational Exposure
CBC should be obtained for all exposed workers at baseline. Follow-up CBC is indicated only for those receiving a zidovudine-containing regimen.
Recommended even if PEP is declined.
Follow-up care is necessary for patients receiving PEP to monitor for adverse effects of the PEP regimen and to maximize adherence to the prescribed regimen. Adherence to a 28-day PEP regimen has historically been modest (40-60%), although newer studies using tenofovir + either lamivudine or emtricitabine as components for PEP regimens show increased rates of adherence. Limited data show similar improved tolerability with tenofovir + emtricitabine plus raltegravir.
If the recommended regimen is not well tolerated, an early switch to an alternative regimen is encouraged to improve adherence. Again, consultation with a clinician experienced in managing PEP should occur when switching to an alternative regimen due to tolerability or resistance.
Recommendations:
• Sequential confidential HIV testing should be obtained at baseline, week 4, and week 12 post-exposure:
– HIV testing at 6 months post-exposure is no longer recommended
– HIV testing of the exposed person at 4 weeks and 12 weeks should be performed with laboratory-based HIV tests rather than rapid point-of-care HIV tests
– If the post-exposure evaluation determined that PEP was indicated, but the exposed person declines PEP, serial testing should still be obtained (see Table 7)
• If at any time the HIV test result is positive, a confirmatory assay must be performed to confirm the diagnosis of HIV infection.
• If the exposed person presents with signs or symptoms of acute HIV seroconversion, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay to diagnose acute HIV infection. (AII) A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available. Immediate consultation with a clinician experienced in managing ART should be sought for optimal treatment options.
When individuals are potentially exposed to HIV, longitudinal medical follow-up is necessary regardless of whether PEP is initiated or completed, in order to test sequentially for HIV infection.
HIV seroconversion will generally occur within 2 to 4 weeks if HIV infection develops after an exposure. HIV testing at baseline, 4 weeks, and 12 weeks is recommended after significant exposures, regardless of whether the individual accepts or declines PEP treatment. Rapid point-of-care HIV tests are slightly less sensitive than laboratory-based HIV tests; therefore, exposed persons should be tested with laboratory-based HIV tests whenever possible.
HIV testing at 6 months after exposure is no longer recommended. Late seroconversion (ie, after 3 months) has been rarely reported and has not been described since 1990. It is unclear if these rare events were related to the original or subsequent exposures. The Medical Care Criteria Committee believes that the benefit of routinely testing all exposed persons for HIV at 6 months is outweighed by the negative consequences of routinely extending post-exposure HIV follow-up testing to 6 months because of the infrequency of late seroconversion, the increased sensitivity of standard HIV tests to detect early infection and seroconversion, and the added anxiety and significant consequences of an additional 3 months of precautions and testing for exposed individuals.
Patients acutely infected with HIV will often experience at least some symptoms of the acute retroviral syndrome. Fever and flu- or mono-like symptoms are common in acute HIV infection but are nonspecific. Rash, mucocutaneous ulcers, oropharyngeal candidiasis, and meningismus are more specific. Symptoms may also include fatigue or malaise, joint pain, headache, loss of appetite, night sweats, myalgias, lymphadenopathy, oral and/or genital ulcers, nausea or diarrhea, or pharyngitis. Acute HIV infection is often not recognized in the primary care setting because of the similarity of the symptom complex with that of the flu or other common illnesses. When infection occurs, the ELISA antibody test will generally be positive within 3 weeks of the onset of symptoms and is virtually always positive within 3 months following exposure. A confirmatory Western blot may yield an indeterminate result during the early stages of seroconversion. When acute HIV seroconversion is suspected based on the clinical scenario, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay to diagnose acute HIV infection. (AII) A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available.
See the following resources for more information:
• Characteristics of FDA-Approved Rapid HIV Tests for further information on available rapid HIV tests
• Diagnosis and Management of Acute HIV Infection for further information on management of acute HIV infection
• AIDS Institute's Voluntary HIV Provider Directory for referral for continued HIV care
Follow-up and Monitoring Following Non-occupational Exposure
Recommendations:
• All patients receiving PEP should be re-evaluated within 3 days of the exposure to further clarify the nature of the exposure, review available source person data, evaluate adherence, and monitor toxicities associated with the PEP regimen. (AIII)
• The exposed person should be evaluated weekly while receiving PEP to assess treatment adherence, side effects of treatment, interval physical complaints, and emotional status. (AIII) Longitudinal care of the exposed person during PEP treatment and the follow-up period should be provided by or in consultation with a clinician experienced in managing nPEP. Emergency Departments and urgent care centers should establish linkages with local HIV providers to facilitate easy referral of patients for follow-up care. Providers who do not have access to a clinician experienced in PEP should use the National Clinicians' Consultation Center PEPline at 1-888-HIV-4911 (1-888-448-4911) for phone consultation. When using the PEPline, providers from New York State should identify themselves as practicing in the State.
• Clinicians should provide risk-reduction counseling to exposed persons to prevent secondary transmission during the 12-week follow-up period. HIV-exposed individuals should be advised to:
– use condoms to prevent potential sexual transmission (AI)
– avoid pregnancy and breastfeeding (AI)
– avoid needle-sharing (AI)
– refrain from donating blood, plasma, organs, tissue, or semen (AI)
During the PEP treatment period, other blood tests may be indicated to monitor for side effects of treatment. The timing and specific testing indicated varies based on the PEP regimen used (see Table 7).
| Key Point: |
| Post-exposure care involves simultaneous attention to multiple issues: the emotional state of the exposed person, adherence to the PEP regimen, monitoring for potential adverse effects, and sequential HIV testing to determine infection status. |
Clinicians should be aware of the resources within the community that offer medical and supportive counseling/adherence services needed following non-occupational exposure.
Table 7. Monitoring Recommendations After Initiation of PEP Regimens Following Non-occupational Exposure
| Baseline | Week 1 |
Week 2 |
Week 3 |
Week 4 |
Week 12 |
|
|---|---|---|---|---|---|---|
| Clinic visit | ✓ |
✓
Or by telephone |
✓
Or by telephone |
✓
Or by telephone |
✓ | |
| Pregnancy test | ✓ | |||||
| Serum liver enzymes, BUN, creatinine, CBC | ✓ | ✓ | ✓ | |||
| HIV test | ✓ | ✓ | ✓ | |||
STI Screening (for exposures unrelated to sexual assault)
:
|
✓ |
✓
(consider) |
||||
| Hepatitis B and C | For post-exposure management for hepatitis B and C, see the section below entitled Non-Occupational Exposures to Hepatitis B and C | |||||
CBC should be obtained for all exposed workers at baseline. Follow-up CBC is indicated only for those receiving a zidovudine-containing regimen.
Recommended even if PEP is declined.
Adherence to the PEP Regimen
Follow-up care is necessary for patients receiving PEP to monitor for adverse effects of the PEP regimen and to maximize adherence to the prescribed regimen. Adherence to a 28-day PEP regimen has historically been modest (40-60%), although newer studies using tenofovir + either lamivudine or emtricitabine as components for PEP regimens show increased rates of adherence. Limited data show similar improved tolerability with tenofovir + emtricitabine plus raltegravir.
If the recommended regimen is not well tolerated, an early switch to an alternative regimen is encouraged to improve adherence. Again, consultation with a clinician experienced in managing PEP should occur when switching to an alternative regimen due to tolerability or resistance.
Sequential HIV Testing
Recommendations:
• Sequential confidential HIV testing should be obtained at baseline, week 4, and week 12 post-exposure:
– HIV testing at 6 months post-exposure is no longer recommended
– HIV testing of the exposed person at 4 weeks and 12 weeks should be performed with laboratory-based HIV tests rather than rapid point-of-care HIV tests
– If the post-exposure evaluation determined that PEP was indicated, but the exposed person declines PEP, serial testing should still be obtained (see Table 7)
• If at any time the HIV test result is positive, a confirmatory assay must be performed to confirm the diagnosis of HIV infection.
• If the exposed person presents with signs or symptoms of acute HIV seroconversion, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay to diagnose acute HIV infection. (AII) A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available. Immediate consultation with a clinician experienced in managing ART should be sought for optimal treatment options.
When individuals are potentially exposed to HIV, longitudinal medical follow-up is necessary regardless of whether PEP is initiated or completed, in order to test sequentially for HIV infection.
HIV seroconversion will generally occur within 2 to 4 weeks if HIV infection develops after an exposure. HIV testing at baseline, 4 weeks, and 12 weeks is recommended after significant exposures, regardless of whether the individual accepts or declines PEP treatment. Rapid point-of-care HIV tests are slightly less sensitive than laboratory-based HIV tests; therefore, exposed persons should be tested with laboratory-based HIV tests whenever possible.
HIV testing at 6 months after exposure is no longer recommended. Late seroconversion (ie, after 3 months) has been rarely reported and has not been described since 1990. It is unclear if these rare events were related to the original or subsequent exposures. The Medical Care Criteria Committee believes that the benefit of routinely testing all exposed persons for HIV at 6 months is outweighed by the negative consequences of routinely extending post-exposure HIV follow-up testing to 6 months because of the infrequency of late seroconversion, the increased sensitivity of standard HIV tests to detect early infection and seroconversion, and the added anxiety and significant consequences of an additional 3 months of precautions and testing for exposed individuals.
Patients acutely infected with HIV will often experience at least some symptoms of the acute retroviral syndrome. Fever and flu- or mono-like symptoms are common in acute HIV infection but are nonspecific. Rash, mucocutaneous ulcers, oropharyngeal candidiasis, and meningismus are more specific. Symptoms may also include fatigue or malaise, joint pain, headache, loss of appetite, night sweats, myalgias, lymphadenopathy, oral and/or genital ulcers, nausea or diarrhea, or pharyngitis. Acute HIV infection is often not recognized in the primary care setting because of the similarity of the symptom complex with that of the flu or other common illnesses. When infection occurs, the ELISA antibody test will generally be positive within 3 weeks of the onset of symptoms and is virtually always positive within 3 months following exposure. A confirmatory Western blot may yield an indeterminate result during the early stages of seroconversion. When acute HIV seroconversion is suspected based on the clinical scenario, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay to diagnose acute HIV infection. (AII) A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available.
See the following resources for more information:
• Characteristics of FDA-Approved Rapid HIV Tests for further information on available rapid HIV tests
• Diagnosis and Management of Acute HIV Infection for further information on management of acute HIV infection
• AIDS Institute's Voluntary HIV Provider Directory for referral for continued HIV care