COMMENTARY

HIV Prophylaxis Following Occupational Exposure: Guideline and Commentary

Barry S. Zingman, MD

Disclosures

January 30, 2013

In This Article

PEP for Exposed Workers Who Are Pregnant or Breastfeeding

Exposed Workers Who Are Pregnant

Recommendations:

Based on increasing clinical experience with ART, PEP is indicated at any time during pregnancy when a significant exposure has occurred, despite possible risk to the woman and the fetus. (AII) Expert consultation should be sought. When occupational exposure to HIV occurs, every effort should be made to initiate PEP within 2 hours. (AII) The recommended PEP regimen is the same for pregnant women as for non-pregnant adults (see the section above entitled Recommended PEP Regimen). (AII)

Before administering PEP to a pregnant woman, the clinician should discuss the potential benefits and risks to her and to the fetus.

The agents listed in Table 7 are all non-preferred agents for use in PEP regimens and are not likely to be used; however, clinicians should be aware that these agents should not be prescribed in exposed workers who are pregnant. Initiation of PEP at any time during pregnancy requires a careful discussion of the risks and benefits.

Table 7. PEP Drugs to Avoid During Pregnancy

Drug(s) to Avoid Toxicity
Efavirenz Teratogenicity
Combination of stavudine and didanosine Mitochondrial toxicity
Nevirapine Hepatotoxicity
Unboosted indinavir in the 2nd or 3rd trimester Substantially lower antepartum indinavir plasma concentrations; risk for nephrolithiasis

 

Key Point
In addition to the risk of seroconversion for the exposed worker, the high viral load levels associated with the acute retroviral syndrome markedly increase the risk of transmission to the fetus or breastfeeding infant.

Although birth defects and adverse effects on human fetuses have generally not been associated with the antiretroviral agents that are currently available, exposure of a fetus to antiretroviral agents during pregnancy carries a theoretical risk of teratogenicity.

For additional information, refer to NYSDOH guidelines on Use of ART in HIV-Infected Pregnant Women.

Exposed Workers Who Are Breastfeeding

Recommendation: Clinicians should advise women who may have been exposed to HIV through occupational exposure to avoid breastfeeding for 3 months after the exposure. (AII) If HIV infection is definitively excluded in the source patient at any time prior to 3 months postexposure, the woman may resume breastfeeding.

Initiation of PEP in exposed workers who are breastfeeding requires careful discussion. Both HIV and antiretroviral drugs may be found in breast milk; therefore, breastfeeding should be avoided for 3 months after the exposure to prevent HIV transmission and potential drug toxicities. Clinicians should discuss the risks and benefits with the exposed worker. The infant's pediatrician should be informed of any potential exposure to HIV or antiretroviral medications.

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