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

Editor's Note:
This guideline was prepared and published by the NYS DOH AIDS Institute HIV Clinical Guidelines Program. It has been republished here. Please note that recommendations are assigned an evidence-based rating and use the rating scheme developed by the Department of Health and Human Services.

What's New -- October 2012 Update
Significant revisions include the following:
  • The Medical Care Criteria Committee now recommends tenofovir + emtricitabine* plus raltegravir as the preferred initial PEP regimen because of its excellent tolerability, proven potency in established HIV infection, and ease of administration. Zidovudine is no longer recommended in the preferred PEP regimen because it is believed to have no clear advantage in efficacy over tenofovir while having significantly higher rates of treatment-limiting side effects.

  • Occupational exposures require urgent medical evaluation. In this update, the Committee further emphasizes recommendations regarding the importance of initiating occupational PEP as soon as possible, ideally within 2 hours of exposure. A first dose of PEP should be offered while evaluation is underway. PEP should not be delayed while awaiting information about the source patient or results of the exposed worker's baseline HIV test.

  • This update incorporates amendments to New York State regulations (10 NYCRR part 63) regarding testing of source patients and access to HIV-related information after occupational exposures (see Appendix C).

  • If the source patient's rapid HIV test result is negative but there has been a risk for HIV exposure in the previous 6 weeks, plasma HIV RNA testing of the source patient is also recommended. In this situation, PEP should be initiated and continued until results of the plasma HIV RNA assay are available.

  • A recommendation has been added that baseline HIV testing of the exposed worker should always be obtained after an occupational exposure, even if the exposed worker declines PEP.

  • Recommendations for follow-up HIV testing of the exposed worker have been changed. Regardless of whether the exposed worker accepts or declines PEP treatment, if the post-exposure evaluation determines that PEP is indicated, repeat HIV testing at 4 weeks and 12 weeks should be obtained. A negative HIV test result at 12 weeks post-exposure reasonably excludes HIV infection related to the occupational exposure; routine testing at 6 months post-exposure is no longer recommended.

  • Appendix B includes an updated comparison of occupational PEP recommendations from the New York State Department of Health AIDS Institute and the Centers for Disease Control and Prevention.

*Lamivudine may be substituted for emtricitabine.

Introduction

The purpose of these guidelines is to provide recommendations for prescribing HIV post-exposure prophylaxis (PEP) following occupational exposure. To develop these guidelines, the New York State Department of Health AIDS Institute's (NYSDOH AI) Medical Care Criteria Committee has reviewed available literature addressing the biologic efficacy, effectiveness, and implementation of PEP, as well as current standards for the use of antiretroviral therapy (ART) in established HIV infection. Because randomized, placebo-controlled clinical trials of PEP in humans have not been conducted and are not feasible to design, the NYSDOH AI guidelines are based on existing published studies, best-practice evidence, and the considered opinion of the expert clinicians in the field of adult HIV medicine who comprise the Medical Care Criteria Committee. Expert opinion was frequently used to arrive at recommendations as the PEP literature leaves many questions unanswered or poorly studied.

New York State recommendations differ from those published by the Centers for Disease Control and Prevention (CDC) (see Appendix B). The guidelines of this committee stress simplicity and tolerability in the approach to PEP, recommending a potent but very well tolerated first-line triple therapy for all significant exposures. Recommended second choice regimens are potent and include the best tolerated boosted protease inhibitors.

These 2012 guidelines update any previously issued guidelines. Revisions are summarized in the What's New box above.

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