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HIV postexposure prophylaxis for healthcare professionals

Kerns, Rachel, PharmD; Sheridan, Dan, MS, RPh

doi: 10.1097/01.NURSE.0000547727.22976.53
Department: Infection Prevention
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At OhioHealth Marion General Hospital in Marion, Ohio, Rachel Kerns is a pharmacist and Dan Sheridan is a medication safety pharmacist. Dan is also a member of the Nursing2019 editorial board.

The authors have disclosed no financial relationships related to this article.

FOR HEALTHCARE workers, the risk of exposure to HIV while providing patient-centered care is rare but consistently present. This article examines the importance of postexposure prophylaxis (PEP) following potential HIV exposure in healthcare workers.

According to the CDC, 58 occupational transmissions of HIV have been confirmed and 150 possible cases have been reported in the US as of December 31, 2013. Healthcare workers have a 0.23% chance of infection if stuck with a needle containing HIV-infected blood (see Defining exposure).1,2

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PEP protocols

In 2013, the CDC released standards to help guide management for occupational exposure to potentially infectious blood or body fluids.1,3 Every healthcare facility should have a staff PEP management plan in place.

The implementation of PEP is determined by comparing the risks and benefits of different circumstances on a case-by-case basis, including:2

  • the timing of the exposure
  • an unknown source of exposure
  • potential drug interactions, such as oral contraceptives, H2-receptor antagonists, proton pump inhibitors
  • the pregnancy status of an exposed employee
  • any resistance to the virus or antiretroviral agents
  • any PEP therapy toxicities.

If a healthcare worker may have been exposed to HIV, PEP should be initiated as soon as possible within 72 hours; PEP has little-to-no benefit after that window of time.1-3 HIV testing is performed at baseline and repeat testing varies depending on the method.2 Antibody-allergen testing is preferred at 6 weeks and 4 months, but antibody testing can also be performed at 6 weeks, 3 months, and 6 months postexposure. The CDC recommends antibody-allergen testing at 4 weeks, 12 weeks, and 6 months, and the New York State Department of Health recommends it at 4 weeks and 12 weeks.2-4

Along with the US Public Health Service, the International Antiviral Society—US panel, and the World Health Organization, the CDC recommends the use of three or more antiviral medications in PEP.1,2,4 The recommended regimen for both pregnant and nonpregnant staff is a combination of emtricitabine and tenofovir disoproxil fumarate (Truvada) once a day, plus raltegravir (Isentress) twice a day. Truvada combines two nucleoside analogue HIV-1 reverse transcriptase inhibitors; raltegravir is an HIV integrase strand transfer inhibitor.

Both medications are used off-label for the purpose of PEP. Although Truvada is FDA-approved for pre-exposure prophylaxis, raltegravir is not. The recommended PEP regimen lasts 28 days and can be discontinued if the patient tests negative for HIV during that time, but the optimal duration of PEP is still unknown.2-7

Other regimens are also acceptable and available, but these should be discussed with a provider. Because tenofovir can increase the risk of renal impairment, alternative regimens should be used in those with renal disease.3,6 For example, a combination of zidovudine and lamivudine (Combivir) may be used as an alternative to emtricitabine and tenofovir.3,8

Components of PEP are typically well tolerated and can be taken without regard to food, but drug toxicity monitoring is recommended. This includes hepatic and renal function testing, complete blood cell count and differential, and hyperglycemia monitoring for those treated with protease inhibitors. Other potential adverse drug reactions such as nausea, abdominal pain, diarrhea, and headaches usually subside within a few weeks.2,6,7

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Safety first

Healthcare workers should take every precaution to protect against potentially infectious body fluids, including the use of gloves, goggles, and other safety devices to prevent injury and occupational transmission of HIV, and they should encourage others to do the same.1 The CDC maintains a PEP hotline (1-888-448-4911), which is staffed with knowledgeable specialists for consultation on occupational PEP.9

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Defining exposure1

Occupational HIV infection is a valid concern among healthcare workers. In evaluating the risk of transmission, an exposure is considered “contact with potentially infectious blood, tissue, or body fluids in a manner that allows for possible transmission of HIV and therefore requires consideration of post-exposure prophylaxis (PEP).” This includes contact with the following:

  • Percutaneous injuries (needle sticks or cuts from sharps or devices that have been in contact with patients)
  • Contact of blood or fluid contaminations with mucous membranes or nonintact skin (chapped or abraded skin, patients with dermatitis). Intact skin is an effective barrier, however, and blood or fluid contaminations of intact skin are not considered an exposure. In research labs and production facilities, contact with HIV without barrier protection requires clinical evaluation and possible PEP.
  • Body fluids that are associated with HIV (blood, semen, vaginal secretions, and other fluids contaminated with visible blood)
  • Potentially infectious body fluids that present an undetermined risk of transmission (cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids)
  • Fluids that present a risk only when containing blood (feces, nasal secretions, saliva, gastric secretions, sputum, sweat, tears, urine, and/or vomitus).
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REFERENCES

1. Centers for Disease Control and Prevention. Occupational HIV transmission and prevention among health care workers. 2016. http://www.cdc.gov/hiv/workplace/healthcareworkers.html.
2. Zachary KC. Management of health care personnel exposed to HIV. UpToDate. 2018. http://www.uptodate.com.
3. Kuhar DT, Henderson DK, Struble KA, et al Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9):875–892.
4. New York State Department of Health: AIDS Institute: Medical Care Criteria Committee. ART regimens for oPEP. 2018. http://www.hivguidelines.org/pep-for-hiv-prevention/occupational/#tab_6.
5. New York State Department of Health: AIDS Institute: Medical Care Criteria Committee. PEP for HIV-exposed workers who are pregnant or breastfeeding. 2018. http://www.hivguidelines.org/pep-for-hiv-prevention/occupational/#tab_8.
    6. Truvada (emtricitabine and tenofovir disoproxil fumarate) tablets, for oral use. Prescribing information. 2018. http://www.gilead.com/~/media/Files/pdfs/medicines/hiv/truvada/truvada_pi.pdf.
    7. Isentress (raltegravir) film-coated tablets, for oral use; Isentress HD (raltegravir) film-coated tablets, for oral use; Isentress (raltegravir) chewable tablets, for oral use; Isentress (raltegravir) for oral suspension. Prescribing information. 2018. http://www.merck.com/product/usa/pi_circulars/i/isentress/isentress_pi.pdf.
    8. Combivir (lamivudine and zidovudine) tablets. Prescribing information. 2015. http://www.accessdata.fda.gov/drugsatfda_docs/label/2015/20857s030lbl.pdf.
    9. Centers for Disease Control and Prevention. PEP. 2018. http://www.cdc.gov/hiv/basics/pep.html.
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