Transcript Slide 1

Antiretroviral Postexposure
Prophylaxis after Sexual, Injection
Drug Use, or Other Nonoccupational
Exposure to HIV in the United States
Recommendations from the U.S.
Department of Health and Human Services
January 2005
About This Presentation
 These slides were developed using the January
2005 recommendations. The intended audience
is clinicians involved in the care of patients with
HIV.
 Users are cautioned that, because of the rapidly
changing field of HIV care, this information
could become out of date quickly. Finally, it is
intended that these slides be used as prepared,
without changes in either content or attribution.
Users are asked to honor this intent.
– AETC NRC
http://www.aids-etc.org
March 2008
AETC National Resource Center, www.aidsetc.org
Evidence of Possible Benefits from
nPEP




Animal studies
Postnatal (mother-to-child) prophylaxis
Occupational PEP
Observational studies of nPEP
March 2008
AETC National Resource Center, www.aidsetc.org
Evidence of Possible Risks from
nPEP (2)
 Impact on risk-reduction behaviors
 ARV side effects and toxicity
 Selection of resistant virus
March 2008
AETC National Resource Center, www.aidsetc.org
Evaluation of Persons Seeking nPEP
 HIV status of person seeking nPEP
 Perform HIV baseline testing on persons
seeking nPEP; use rapid test if possible
 Time and frequency of exposure
 nPEP is less likely to be effective >72 hours
postexposure
 nPEP should be used infrequently
March 2008
AETC National Resource Center, www.aidsetc.org
Evaluation of Persons Seeking nPEP:
HIV Status of Source
 HIV status of source: HIV positive
 Consider nPEP if within 72 hours of exposure
 When possible, interview source to determine
ARV use and most recent viral load
 HIV status of source: Unknown
 Determine whether source is available for
testing
 If source is from group with high prevalence of
HIV infection, risk of transmission might be
increased
 Do not delay initiation of nPEP for source testing
March 2008
AETC National Resource Center, www.aidsetc.org
Transmission Risk from the Exposure
 Determine the specific sexual, injection
drug use, or other behavior that led
person to seek nPEP (see Estimated
Per-Act Risk by Exposure Route)
 Determine relative risk for HIV exposure
using algorithm for evaluation and
treatment and per-act risk for acquisition
of HIV
March 2008
AETC National Resource Center, www.aidsetc.org
Estimated Per-Act Risk for Acquisition
of HIV by Exposure Route
Exposure Route
Blood transfusion
Risk per 10,000
exposures
9,000
Needle-sharing injection drug use
67
Receptive anal intercourse
50
Percutaneous needle stick
30
Receptive penile-vaginal intercourse
10
Insertive anal intercourse
6.5
Insertive penile-vaginal intercourse
10
Receptive oral intercourse
Insertive oral intercourse
March 2008
1
0.5
AETC National Resource Center, www.aidsetc.org
Recommendations for Use of ARVs for nPEP
Substantial
exposure risk
< 72 hours since
exposure
>72 hours since
exposure
Source patient
known to be HIV+
Source patient of
unknown HIV status
nPEP recommended
Case-by-case
determination
March 2008
Negligible
exposure risk
nPEP not
recommended
AETC National Resource Center, www.aidsetc.org
Assessing Risk of HIV Exposure
Substantial Risk
of HIV Exposure
Exposure of:
 vagina, rectum, eye, mouth or
other mucous membrane, nonintact
skin, or percutaneous contact
With:
 blood, semen, vaginal secretions,
rectal secretions, breast milk, or any
body fluid that is visibly
contaminated with blood
When the source is
known to be HIV infected
March 2008
Negligible Risk
of HIV Exposure
Exposure of:
 vagina, rectum, eye, mouth or
other mucous membrane, intact or
nonintact skin, or percutaneous
contact
With:
 urine, nasal secretions, saliva,
sweat, or tears if not visibly
contaminated with blood
Regardless of the known or
suspected HIV status
of the source
AETC National Resource Center, www.aidsetc.org
Preferred ARV Regimens for nPEP
NNRTI based
EFV + (3TC or FTC) + (ZDV or
TDF) for 28 days
Do not administer EFV to pregnant
women
PI based
LPV/RTV (Kaletra) + (3TC or FTC)
+ ZDV for 28 days
March 2008
AETC National Resource Center, www.aidsetc.org
Considerations for All Patients Treated
with nPEP
 Use starter packs
 Clinicians not experienced using ART should
consult with ID or other HIV-care specialists
 Facilitate adherence
 Monitor for signs and symptoms associated with
acute infection
 Follow-up HIV tests at 4-6 weeks, 3 months, and
6 months to determine whether infection has
occurred
 Screening for STDs, hepatitis B and C, and
pregnancy should be offered
 HIV prevention counseling
 Reporting and confidentiality
March 2008
AETC National Resource Center, www.aidsetc.org
Lab Evaluations for nPEP
Test
HIV
antibody
Baseline
During
nPEP
4-6 Weeks
after
Exposure
3 Months
after
Exposure
6 Months
after
Exposure
E
E
E
E, S
Blood
count
E
E
Serum
liver
enzymes
E
E
STDs
E,S
E
Hep B
serology
E,S
E
E
E
E = exposed patient; S = source patient
March 2008
AETC National Resource Center, www.aidsetc.org
Lab Evaluations for nPEP (2)
Test
Baseline
During
nPEP
4-6 Weeks
after
Exposure
3 Months
after
Exposure
6 Months
after
Exposure
Pregnancy test
(for women of
reproductive
age)
E
E
E
HIV viral load
S
E
E
E
HIV resistance
testing
S
E
E
E
CD4 count
S
E
E
E
March 2008
AETC National Resource Center, www.aidsetc.org
Special Considerations for Vulnerable
Populations
 Pregnant women and women of childbearing
potential
 Children
 Sexual assault survivors
 Inmates
 Injection drug users
March 2008
AETC National Resource Center, www.aidsetc.org
About This Slide Set
 This presentation was prepared by
Mark Vogel, MA, for the AETC National
Resource Center in January 2005
 See the AETC NRC website for the
most current version of this
presentation: http://www.aids-etc.org
March 2008
AETC National Resource Center, www.aidsetc.org