HIV Occupational Exposure: USPHS Updates Guidelines

Laurie Barclay, MD

August 09, 2013

After any occupational exposure to HIV, healthcare personnel (HCP) should immediately receive a postexposure prophylaxis (PEP) regimen containing at least 3 antiretroviral drugs, according to updated guidelines published in the September issue of Infection Control and Hospital Epidemiology. The current recommendations from the United States Public Health Service (USPHS) update the 2005 guidelines for management of HCP with occupational HIV exposure and use of PEP.

A major change in the recommendation refers to the number of drugs included in the PEP regimen. The previous guidelines recommended evaluating the risk level associated with specific exposures to help determine the optimal number of antiretroviral drugs for PEP. In contrast, the current recommendations call for consistent use of a combination of 3 or more drugs for all occupational exposures to HIV.

"Preventing exposures should be the leading strategy to prevent occupational HIV infections," guidelines author David Kuhar, MD, a medical epidemiologist from the Centers for Disease Control and Prevention's Division of Healthcare Quality Promotion, said in a Society for Healthcare Epidemiology of America news release. "However, when an exposure occurs, it should be considered an urgent medical concern and a PEP regimen should be started right away, ideally within hours of the potential exposure."

An interagency USPHS working group, including members from the Centers for Disease Control and Prevention, National Institutes of Health, US Food and Drug Administration, and the Health Resources and Services Administration, developed these guidelines with input from an external expert panel.

To improve compliance and completion of the full PEP regimen, many of the revised recommendations aim to improve tolerability of the PEP regimen. Drugs in the currently recommended regimens are better tolerated than those previously recommended.

Specific Recommendations

  • The guidelines emphasize primary prevention strategies and prompt reporting and management of occupational exposures.

  • If possible, the HIV status of the exposure source patient should be determined to guide the need for HIV PEP.

  • Initiating PEP should be the first priority and should not be delayed pending expert consultation, which is also recommended.

  • PEP regimens should contain 3 (or more) antiretroviral drugs for 4 weeks.

  • Follow-up appointments should begin within 72 hours of HIV exposure and should include follow-up HIV testing, monitoring for drug toxicity, and counselling.

  • HIV testing should generally continue for 6 months after exposure.

  • HIV testing may be concluded at 4 months, provided a newer fourth-generation HIV antigen/antibody combination test is used for follow-up testing.

  • The updated guidelines should be distributed to emergency physicians and other providers as needed, because many HCP exposures occur outside of normal office hours. Emergency physicians or other providers who are not experts in HIV treatment or in the use of antiretroviral therapy medications often oversee initial management of HIV exposure in emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, environmental maintenance personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students, and trainees.

"To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures," the guidelines authors write.

Some of the expert panel consultants report various financial disclosures with Bristol-Myers Squibb, Janssen, Merck, ViiV, Gilead, and GlaxoSmithKline. The other authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. 2013;34:875-892. Full text

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