Human Immunodeficiency Virus Book

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HIV ExposureAka: HIV Postexposure Prophylaxis, HIV Prophylaxis, HIV Occupational Exposure, HIV Exposure Prophylaxis, Postexposure Prophylaxis for HIV, HIV PEP

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  1. See Also
    1. HIV Transmission
    2. Sexually Transmitted Disease
    3. Bloodborne Pathogen Exposure
    4. Rape Management
  2. Epidemiology: Risk of HIV Infection after single exposure
    1. Transfusion of HIV positive blood: >90%
        1. U.S. Risk: less than 1 per 100,000 transfusions are HIV contaminated
    2. Percutaneous needle stick: 0.3%
    3. Receptive anal intercourse: 0.5%
    4. Receptive vaginal intercourse: 0.1%
    5. Insertive intercourse: 0.05 to 0.07%
    6. Oral intercourse: 0.005 to 0.01%
    7. Blood to mucous membrane: 0.09%
    8. Blood to non-intact skin: <0.1%
    9. Maternal to fetal vertical transmission: 13-39% if no intrapartum AZT
  3. Indications: Postexposure prophylaxis
    1. Occupational HIV exposure (needle stick)
    2. Non-occupational HIV exposure
      1. Isolated high risk exposure within last 72 hours
      2. Exposure to HIV positive or high risk sexual partner
  4. Protocol: Medications
    1. Start within hours of exposure (under 24 to 48 hours)
    2. Triple Therapy for 4 weeks
      1. First two medications: AZT and 3TC (or Combivir)
        1. Zidovudine (AZT) 300 mg PO bid and
        2. Lamivudine (3TC) 150 mg PO bid
      2. Third medication (choose one)
        1. Indinavir (IDV) 800 mg PO tid or
        2. Nelfinavir (Viracept) 750 mg PO tid or
        3. Nelfinavir (Viracept) 1250 mg PO bid
    3. Obtain baseline labs to monitor for adverse reaction
      1. Pregnancy Test
      2. Complete Blood Count with differential and platelets
      3. Urinalysis
      4. Renal Function tests
        1. Blood Urea Nitrogen (BUN)
        2. Serum Creatinine
      5. Liver Function Tests
        1. Aspartate Aminotransferase
        2. Alanine Aminotransferase
        3. Alkaline Phosphatase
        4. Total Bilirubin
  5. Protocol: Less Severe HIV Exposure
    1. Exposure criteria
      1. Percutaneous exposure
        1. Superficial injury
        2. Solid needle
      2. Mucous membrane or non-intact skin exposure
        1. Small volume exposure (i.e. a few drops)
    2. Source Status
      1. HIV-Positive Class 1 (asymptomatic, viral load <1500)
        1. Administer two drug prophylaxis (see above)
      2. HIV-Positive Class 2 (symptomatic, AIDS, high load)
        1. Percutaneous exposure: three drug prophylaxis
        2. Mucous membrane or non-intact skin: 2 drug protocol
      3. Source with Unknown HIV Status or unknown source
        1. No prophylaxis usually needed
        2. Consider two drug protocol if high risk setting
      4. HIV Negative Source: No prophylaxis needed
  6. Protocol: More Severe HIV Exposure
    1. Exposure criteria
      1. Percutaneous exposure
        1. Deep Puncture Wound (especially in vascular tissue)
        2. Large-bore hollow needle
        3. Blood on needle used in patient's artery or vein
      2. Mucous membrane or non-intact skin exposure
        1. Large volume exposure (e.g. large blood splash)
    2. Source Status
      1. HIV-Positive Class 1 (asymptomatic, viral load <1500)
        1. Percutaneous exposure: three drug prophylaxis
        2. Mucous membrane or non-intact skin: 2 drug protocol
      2. HIV-Positive Class 2 (symptomatic, AIDS, high load)
        1. Three drug postexposure prophylaxis (see above)
      3. Source with Unknown HIV Status or unknown source
        1. No prophylaxis usually needed
        2. Consider two drug protocol if high risk setting
        3. Consider giving first dose and testing source
          1. HIV Test results can now be obtained same day
      4. HIV Negative Source: No prophylaxis needed
  7. Monitoring
    1. Follow-up weekly during protocol
  8. Efficacy
    1. Zidovudine alone: 81% reduction in HIV seroconversion
      1. Zidovudine not used alone anymore due to resistance
      2. Cardo (1997) N Engl J Med 337:1485
  9. Resources
    1. National HIV Clinicians Consultation Center
      1. http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html
      2. Phone (PepLine): 1-888-HIV-4911 (health care providers only)
  10. Reference
    1. (1996) MMWR Morb Mortal Wkly Rep 45:468
    2. (2001) MMWR Morb Mortal Wkly Rep 50(RR-11):24
    3. Merchant (2000) Ann Emerg Med 36:371

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