COMMENTARY

HIV Prophylaxis Following Occupational Exposure: Guideline and Commentary

Barry S. Zingman, MD

Disclosures

January 30, 2013

In This Article

Follow-Up and Monitoring of the Exposed Worker Following Occupational Exposure

Recommendations:

All exposed workers receiving PEP should be re-evaluated within 3 days of the exposure. (AIII) This allows for further clarification of the nature of the exposure, review of available source patient data, and evaluation of adherence to and toxicities associated with the PEP regimen.

The exposed worker should be evaluated weekly while receiving PEP to assess treatment adherence, side effects of treatment, interval physical complaints, and emotional status. (AIII) Longitudinal care of the exposed worker during PEP treatment and the follow-up period should be provided by an occupational health provider familiar with PEP or directly by or in consultation with a clinician experienced in managing PEP. Providers who do not have access to a clinician experienced in PEP should use the National Clinicians' Consultation Center PEP line at 1-888-HIV-4911 (1-888-448-4911) for phone consultation. When using the PEP Line, providers from New York State should identify themselves as such.

Clinicians should provide risk-reduction counseling to HIV-exposed workers to prevent secondary transmission during the 12-week follow-up period. HIV-exposed workers should be advised to:

   - use condoms to prevent potential sexual transmission

   - avoid pregnancy and breastfeeding

   - avoid needle-sharing

   - refrain from donating blood, plasma, organs, tissue, or semen

During the PEP treatment period, other blood tests may be indicated to monitor for side effects of treatment. The timing and specific testing indicated varies based on the PEP regimen used (see Table 6).

Table 6. Monitoring Recommendations After Initiation of PEP Regimens Following Occupational Exposurea

  Baseline Week 1 Week 2 Week 3 Week 4 Week 12
Clinic visit
Or by telephone

Or by telephone

Or by telephone
 
Pregnancy test          
Serum liver enzymes, BUN, creatinine, CBCb      
HIV testc      

a For post-exposure management for hepatitis B and C, see the section below entitled Occupational Exposures to Hepatitis B and C. b CBC should be obtained for all exposed workers at baseline.Follow-up CBC is indicated only for those receiving a zidovudine-containing regimen. c Recommended even if PEP is declined.

Post-exposure care involves simultaneous attention to multiple issues: the emotional state of the exposed worker, adherence to the PEP regimen, monitoring for potential adverse effects, and sequential HIV testing to exclude acquisition of infection. Clinicians should be aware of the resources within the community that offer medical and counseling services needed following occupational exposure.

Adherence to the PEP Regimen

Follow-up care is necessary for patients receiving PEP to monitor for adverse effects of the PEP regimen and to maximize adherence to the prescribed regimen. Adherence to a 28-day PEP regimen has historically been modest (40-60%),[29,30,31] although newer studies using tenofovir + either lamivudine or emtricitabine as components for PEP regimens show increased rates of adherence.[20,21] Limited data show similar improved tolerability with tenofovir + emtricitabine plus raltegravir.[22,23]

If the recommended regimen is not well tolerated, an early switch to an alternative regimen is encouraged to improve adherence. Consultation with a clinician experienced in managing PEP should occur when switching to an alternative regimen due to tolerability or resistance.

Sequential HIV Testing

Recommendations:

Sequential confidential HIV testing should be obtained at baseline, week 4, and week 12 post-exposure:

   - HIV testing at 6 months post-exposure is no longer recommended

   - HIV testing of the exposed worker at 4 weeks and 12 weeks should be performed with laboratory-based HIV tests rather than rapid point-of-care HIV tests

   - If the post-exposure evaluation determined that PEP was indicated, but the exposed worker declines PEP, serial testing should still be obtained (see Table 6)

If at any time the HIV test result is positive, a confirmatory assay must be performed to confirm the diagnosis of HIV infection.

If the exposed worker presents with signs or symptoms of acute HIV seroconversion, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay (AII) to diagnose acute HIV infection. A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available. Immediate consultation with a clinician experienced in managing ART should be sought for optimal treatment options.

When workers are potentially exposed to HIV, longitudinal medical follow-up is necessary regardless of whether PEP is initiated or completed, in order to test sequentially for HIV infection.

HIV seroconversion will generally occur within 2 to 4 weeks if chronic HIV infection develops after an exposure. HIV testing at baseline, 4 weeks, and 12 weeks is recommended after significant exposures, regardless of whether the worker accepts or declines PEP treatment. Rapid point-of-care HIV tests are slightly less sensitive than laboratory-based HIV tests; therefore, exposed workers should be tested with laboratory-based HIV tests whenever possible.

HIV testing at 6 months after exposure is no longer recommended. Late seroconversion (ie, after 3 months) has been rarely reported and has not been described since 1990.[32,33] It is unclear if these rare events were related to the original or subsequent exposures. Taking into consideration the infrequency of this occurrence, the increased sensitivity of standard HIV tests to detect early infection and seroconversion, and the added anxiety and significant consequences of an additional 3 months of precautions and testing for exposed workers, this Committee believes that the benefit of routinely testing all workers for HIV at 6 months is outweighed by the negative consequences of routinely extending post-exposure HIV follow-up testing to 6 months.

Patients acutely infected with HIV will often experience at least some symptoms of the acute retroviral syndrome. Fever and flu- or mono-like symptoms are common in acute HIV infection but are nonspecific. Rash, mucocutaneous ulcers, oropharyngeal candidiasis, and meningismus are more specific. Symptoms may also include fatigue or malaise, joint pain, headache, loss of appetite, night sweats, myalgias, lymphadenopathy, oral and/or genital ulcers, nausea or diarrhea, or pharyngitis. Acute HIV infection is often not recognized in the primary care setting because of the similarity of the symptom complex with that of the flu or other common illnesses. When infection occurs, the ELISA antibody test will generally be positive within 3 weeks of the onset of symptoms and is virtually always positive within 3 months following exposure. A confirmatory Western blot may yield an indeterminate result during the early stages of seroconversion. When acute HIV seroconversion is suspected based on the clinical scenario, an HIV serologic screening test should be used in conjunction with a plasma HIV RNA assay to diagnose acute HIV infection. A fourth-generation HIV antigen/antibody combination test is the preferred serologic screening test if available.

See the following resources for more information:

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....