New guidelines from the United States Public Health Service update the recommendations for the management of healthcare personnel (HCP) with occupational exposure to HIV and use of postexposure prophylaxis (PEP). The guidelines, published online today in Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA), emphasize the immediate use of a PEP regimen containing three or more antiretroviral drugs after any occupational exposure to HIV.
The PEP regimens recommended in the guidelines encourage the consistent use of a combination of three or more drugs, that are better tolerated than those recommended in the previously published guidelines from 2005, for all occupational exposures to HIV. The guidance eliminates the previous recommendation to assess the level of risk associated with individual exposures to help determine the appropriate number of drugs recommended for PEP.
"Preventing exposures should be the leading strategy to prevent occupational HIV infections," said David Kuhar, MD, an author of the guidelines and medical epidemiologist with the Centers for Disease Control and Prevention's (CDC) Division of Healthcare Quality Promotion. "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."
Expert consultation should be sought, but not at the expense of delaying treatment. Exposed HCP taking HIV PEP should complete a full four-week regimen and undergo follow-up HIV testing, monitoring for drug toxicity and counseling, beginning with follow-up appointments within 72 hours of the exposure. If a newer 4th generation HIV antigen/antibody combination test is used for follow-up testing, an option to conclude HIV testing at 4 months, rather than the recommended 6 months after exposure, is provided. Many of the revised recommendations are intended to make the PEP regimen better tolerated, increasing the possibility that HCP complete the full regimen.
The guidelines were developed by an interagency Public Health Service working group comprised of representatives from the CDC, National Institutes of Health, Food and Drug Administration and the Health Resources and Services Administration, in consultation with an external expert panel. The updated revisions were based upon expert opinion.
HCP might include emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, environmental maintenance personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students and trainees. Many HCP exposures to HIV occur outside of health clinic hours of operation and initial exposure management is often overseen by emergency physicians or other providers who are not experts in the treatment of HIV infection or the use of antiretroviral medications. As such, the updated guidelines should be distributed and made readily available to emergency physicians and other providers as needed.
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David T. Kuhar, MD; David K. Henderson, MD; Kimberly A. Struble, PharmD; Walid Heneine, PhD; Vasavi Thomas, RPh, MPH; Laura W. Cheever, MD, ScM; Ahmed Gomaa, MD, ScD, MSPH; Adelisa L. Panlilio, MD; for the US Public Health Service Working Group. "Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis." Infection Control and Hospital Epidemiology 34:9 (September 2013).