COMMENTARY

HIV Prophylaxis Following Occupational Exposure: Guideline and Commentary

Barry S. Zingman, MD

Disclosures

January 30, 2013

In This Article

HIV Prophylaxis Following Occupational Exposure: Expert Commentary

A risk for HIV transmission in occupational settings was identified soon after AIDS was first described in the early 1980s.1 Fear of transmission was rampant, particularly before the causative agent was identified, modes of transmission were recognized, and zidovudine (AZT), the first therapeutic agent, became available. Fifty-four documented HIV seroconversions occurred among healthcare workers in the United States between 1985 and 1995,2 stoking worry among workers and exacerbating the isolation and stigma experienced by those who were already afflicted by this often fatal illness.

Our approach to preventing occupational HIV infection has evolved, mirroring some aspects of the progress in the epidemic but overall lagging behind the major advances in the field. When AZT became available, workers with significant exposures were often offered this treatment in the hope that it would prevent infection. The ACTG 076 study of AZT in preventing mother-to-child transmission of HIV infection,3 as well as an international case-control study of postexposure use of AZT,4,5 firmly set guidelines on the path of recommending AZT alone or in combination with other antiretroviral agents for occupational prevention. No prospective randomized occupational HIV prophylaxis study could be done after this; and, as combination antiretroviral therapy became the standard of HIV treatment, combination antiretroviral therapy, including AZT and protease inhibitors (particularly indinavir and lopinavir/ritonavir), became standard practice after significant occupational exposures.

No proven HIV transmission after occupational exposure has now been reported in the United States since 1999,2 at least in part due to rapid initiation of potent postexposure prophylaxis (PEP). At the same time, other nucleoside analog antiretrovirals (particularly tenofovir) have largely replaced AZT, better tolerated protease inhibitors have been released, and new classes of antiretroviral drugs are now major components of preferred regimens.6 (Tenofovir with or without emtricitabine has shown potency and tolerability not only in established HIV treatment but also in a number of studies of postexposure and pre-exposure HIV prophylaxis.7-11

The consequences of continued use of AZT and older protease inhibitors in HIV PEP regimens have been significant. Up to half of workers receiving these agents experience significant side effects and often never complete the intended regimen.12 Personal lives and work are disrupted, and expensive medication regimens may be discontinued or changed, further driving up costs and complexity, all often after relatively low-risk exposures. Occupational health and other providers have had little guidance or comfort level in the use of newer antiretroviral agents in PEP and have often felt compelled to recommend continuing poorly tolerated but guideline-recommended older agents.

Similarly established since the mid-1980s is the practice of HIV testing at baseline, 4-6 weeks, 3 months, and 6 months after potential HIV occupational exposures. This never changed despite major advances in understanding HIV pathogenesis and seroconversion, as well as significant improvement in HIV testing methodologies. In addition, exposed workers were counseled to continue practicing safe sex and to avoid pregnancy and nursing for 6 months, causing prolonged periods of anxiety and disruption, compounding the effects of an oftentimes minor incident many months before, and despite the use of potent HIV PEP.

It is with this background that the New York State Department of Health (NYS DOH) AIDS Institute's adult HIV guidelines committee undertook a comprehensive re-evaluation of its HIV occupational PEP guideline and has released a long-awaited and critically important revision. These changes should be quickly and broadly adopted, as they are expected to dramatically change the experience of workers after potential HIV exposures.

The major advances in the NYS DOH occupational PEP guideline are:

(1) Change of the preferred PEP regimen to a significantly better tolerated but highly potent combination of tenofovir + emtricitabine (or lamivudine) + raltegravir. The inclusion of tenofovir rather than AZT, and the integrase inhibitor raltegravir rather than protease inhibitors, will dramatically change the tolerability of HIV PEP regimens.

(2) A new list of alternative PEP regimens that include better tolerated potent ritonavir-boosted protease inhibitors.

(3) Shortening of the time of HIV testing after exposure to 3 months if modern, blood-based, standard (not rapid) HIV testing is performed.

(4) Consideration of HIV RNA testing in the source patient if he or she has had a recent high-risk exposure but tests HIV negative on antibody testing.

This is the first major occupational PEP guideline revision in the United States since 2005.12 The Centers for Disease Control and Prevention is currently revising its occupational PEP guideline as well, and many similar changes are expected to be announced in the near future.

Readers of the NYS DOH PEP guideline will note that, in addition to comprehensive, up-to-date treatment of issues in HIV PEP, it also provides information specific to New York (for example, related to NYS HIV testing law, including source testing), which could serve as a model in other areas.

The latest HIV occupational PEP guideline from the NYS DOH brings the many advances in HIV testing and care to exposed workers, promoting an approach that will minimize adverse effects of treatment, improve treatment completion, and lessen the anxiety and disruption that almost all workers experience after a potential exposure. Our coworkers deserve it; it is far overdue.

References

  1. Centers for Disease Control (CDC). Acquired immunodeficiency syndrome (AIDS): precautions for health-care workers and allied professionals. MMWR Morb Mortal Wkly Rep. 1983;32:450-451. Abstract

  2. Centers for Disease Control and Prevention. Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2010. Updated May 2011. http://www.cdc.gov/HAI/organisms/hiv/Surveillance-Occupationally-Acquired-HIV-AIDS.html Accessed January 14, 2013.

  3. Centers for Disease Control and Prevention (CDC). Zidovudine for the prevention of HIV transmission from mother to infant. MMWR Morb Mortal Wkly Rep. 1994;43:285-287. Abstract

  4. Centers for Disease Control and Prevention (CDC). Case-control study of HIV seroconversion in health-care workers after percutaneous exposure to HIV-infected blood--France, United Kingdom, and United States, January 1988-August 1994. MMWR Morb Mortal Wkly Rep. 1995;44:929-933. Abstract

  5. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997;337:1485-1490. Abstract

  6. US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Updated March 27, 2012. http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf Accessed January 14, 2013.

  7. Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363:2587-2599. Abstract

  8. Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434. Abstract

  9. Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367:399-410. Abstract

  10. Van Damme L, Corneli A, Ahmed K, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367:411-422. Abstract

  11. Mayer KH, Mimiaga MJ, Cohen D, et al. Tenofovir DF plus lamivudine or emtricitabine for nonoccupational postexposure prophylaxis (NPEP) in a Boston Community Health Center. J Acquir Immune Defic Syndr. 2008;47:494-499. Abstract

  12. Panlilio AL, Cardo DM, Grohskopf LA, Heinine W, Ross CS, US Public Health Service. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005;54:1-17.

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