HIV Exposure

Aka: HIV Exposure, HIV Postexposure Prophylaxis, HIV Post Exposure Prophylaxis, HIV Prophylaxis, HIV Occupational Exposure, HIV Exposure Prophylaxis, Postexposure Prophylaxis for HIV, HIV PEP

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II. Risk Factors: Exposure Source

  1. See HIV Risk Factor

III. Epidemiology: Risk of HIV Transmission after single exposure to an HIV positive source

  1. Fluid types
    1. Fresh Blood > Dried Blood > Semen > Urine > Saliva > Vomit
    2. Bite wounds are lower risk (unless accompanied by blood to blood exposure)
  2. Transfusion of HIV positive blood: >90%
    1. U.S. Risk: 1 per 2 Million transfusions are HIV contaminated
  3. Maternal to fetal vertical transmission
    1. Risk 13-39% if no intrapartum AZT
  4. Receptive anal intercourse: 0.5%
  5. Percutaneous Needle Stick (hollow bore): 0.3% (1 in 300)
  6. Receptive vaginal intercourse: 0.1%
  7. Blood to non-intact skin: <0.1%
  8. Blood to mucous membrane: 0.09%
  9. Insertive intercourse: 0.05 to 0.07%
  10. Oral intercourse: 0.005 to 0.01%

IV. Indications: Postexposure Prophylaxis

  1. Occupational HIV Exposure (Needle Stick)
  2. Non-occupational HIV Exposure
    1. Isolated high risk exposure within last 72 hours
    2. Exposure to HIV positive or high risk sexual partner

V. Evaluation: Define the source patient status

  1. Rapid HIV Testing is available at many centers
    1. Some centers are also able to test p24 Antigen to identify early HIV (Acute Retroviral Syndrome)
    2. Many (but not all) U.S. states allow for testing a source patient's blood without a consent
  2. Unknown source
  3. HIV status unknown
  4. HIV negative
  5. HIV positive Class I
    1. Asymptomatic HIV or
    2. HIV Viral Load <1500 RNA copies/ml
  6. HIV positive Class II
    1. Symptomatic HIV Infection or
    2. AIDS or
    3. Acute seroconversion or
    4. HIV Viral Load >1500 RNA copies/ml

VI. Precautions

  1. Three drug regimens are preferred in all cases as of 2013
  2. All post-exposure protocols have significant risks
    1. Serious potential adverse effects (some are life threatening)
    2. Serious Drug Interactions (some are life threatening)
  3. Consultation with local HIV experts is recommended unless treating physician is comfortable with these protocols and medications

VII. Evaluation: Define the Needle Stick exposure severity

  1. Less severe
    1. Solid needle exposure or
    2. Superficial injury
  2. More severe
    1. Large bore hollow needle or
    2. Deep needle puncture or
    3. Visible blood on device or
    4. Needle used in patient's artery or vein

VIII. Protocol: Post-exposure Prophylaxis following Needle Stick

  1. All HIV Prophylaxis is with 3 drug regimens as of 2013)
  2. Source HIV positive Class I (asymptomatic, viral load <1500)
    1. LESS SEVERE: Basic 2 drug Post-exposure Prophylaxis (3 drug regimen as of 2013)
    2. MORE SEVERE: Expanded 3 drug Post-exposure Prophylaxis
  3. Source HIV positive Class II (symptomatic, AIDS, acute seroconversion, viral load >1500)
    1. Expanded 3 drug Post-exposure Prophylaxis
  4. Source HIV STATUS UNKNOWN or unknown source (regardless of exposure severity)
    1. HIGH RISK patient or community: Consider basic 2 drug Post-exposure Prophylaxis (3 drug regimen as of 2013)
    2. LOW RISK patient or community: No Post-exposure Prophylaxis

IX. Protocol: Post-exposure Prophylaxis following MUCOUS MEMRANE exposure and NON-INTACT SKIN exposure (e.g. dermatitis, open wound)

  1. All HIV Prophylaxis is with 3 drug regimens as of 2013)
  2. Source HIV positive Class I (aymptomatic and viral load <1500)
    1. SMALL VOLUME exposure: Consider basic 2 drug Post-exposure Prophylaxis (3 drug regimen as of 2013)
    2. LARGE VOLUME exposure: Basic 2 drug Post-exposure Prophylaxis (3 drug regimen as of 2013)
  3. Source HIV positive Class II (symptomatic, AIDS, acute seroconversion, viral load>1500)
    1. SMALL VOLUME exposure: Basic 2 drug Post-exposure Prophylaxis (3 drug regimenas of 2013)
    2. LARGE VOLUME exposure: Expanded 3 drug Post-exposure Prophylaxis
  4. Source HIV STATUS UNKNOWN or unknown source
    1. HIGH RISK patient or community AND LARGE VOLUME exposure: Consider basic 2 drug Post-exposure Prophylaxis (3 drug regimenas of 2013)
    2. LOW RISK patient or community OR SMALL VOLUME exposure: No Post-exposure Prophylaxis

X. Protocol: Simplified guidelines (preferred regimen 2013)

  1. Precaution
    1. Three drug regimen is preferred in most cases in U.S. as of revised 2013 guidelines
      1. Replaces 2 drug regimens in mild exposures
    2. Antiretrovirals have serious side effects and require discussion of risks prior to starting
    3. Drug Interactions are also common (e.g. Tivicay interacts with cations and CYP3A4 inducers)
    4. All nRTI options can cause Lactic Acidosis and hepatitic Steatosis
    5. Truvada will be generic in Fall 2020, but cost of HIV Post-exposure Prophylaxis still exceeds $3000
  2. Course
    1. Start within hours of exposure (within 24 to 36 hours is preferred, consult if >72 hours)
    2. Continue for 28 days
    3. Consider longterm HIV Preexposure Prophylaxis (HIV PrEP) if ongoing risk
  3. Preferred regimen
    1. Raltegravir (Isentress or RAL) 400 mg orally twice daily OR Tivicay (Dolutegravir) 50 mg orally daily AND
    2. Truvada (Tenofovir/Viread/TDF 300 mg and Emtricitabine/Emtriva/FTC 200 mg) one orally once daily
  4. Alternative: Combinations (Combination regimens- choose one option from each group)
    1. Choose one option from each of two groups (each option contain 1-2 medications)
    2. Group 1: Non-nRTI options (choose one)
      1. Raltegravir (Isentress or RAL) 400 mg orally twice daily
      2. Darunavir (Prezista or DRV) 800 mg orally daily AND Ritonavir (Norvir or RTV) 100 mg orally daily
      3. Etravirine (Intelence or ETR) 200 mg orally twice daily
      4. Rilpivirine (Edurant=RPV) 25 mg orally once daily
      5. Atazanavir-Ritonavir (Reyataz/RTV or ATV/r) 300/100 mg orally daily
      6. Lopinavir-Ritonavir (LPV/RTV, LPV/r, Kaletra) 400/100 orally twice daily
      7. Dolutegravir (Trivicay) 50 mg orally daily
    3. Group 2: Double nRTI options (Choose one)
      1. Truvada (Tenofovir-Viread-TDF 300 mg AND Emtricitabine-Emtriva-FTC 200 mg) once daily
      2. Combivir (Zidovudine-Retrovir-ZDV-AZT 300 mg AND Lamivudine-Epivir-3TC 150 mg) twice daily
      3. Tenofovir (Viread-TDF) 300 mg daily AND Lamivudine (Epivir-3TC) 300 mg daily
      4. Zidovudine (Retrovir-ZDV-AZT) 300 mg twice daily AND Emtricitabine (Emtriva-FTC) 200 mg daily
  5. Alternative: Single tablet regimen
    1. Stribild once daily (combination tablet)
      1. Truvada (Tenofovir/TDF 300 mg and Emtriva/FTC 200 mg) AND
      2. Elvitegravir/EVG (with Cobicistat enhancer)
  6. References
    1. Kuhar (2013) Infect Control Hosp Epidemiol 34(9):875-92 [PubMed]

XI. Lab: Monitoring - Baseline labs to monitor for adverse reaction

  1. Pregnancy Test
  2. Complete Blood Count with differential and Platelets
  3. Urinalysis
  4. Renal Function tests
    1. Blood Urea Nitrogen (BUN)
    2. Serum Creatinine
  5. Liver Function Tests
    1. Aspartate Aminotransferase
    2. Alanine Aminotransferase
    3. Alkaline Phosphatase
    4. Total Bilirubin

XII. Lab: HIV-related testing

  1. HIV Antibody schedule
    1. Baseline
    2. Week 4-6 post-exposure
    3. Month 3 post-exposure
    4. Month 6 post-exposure
  2. Complete Blood Count (CBC)
    1. Baseline
    2. Week 2 post-exposure
    3. Week 4 post-exposure
  3. HIV RNA PCR indications
    1. Exposed patient with symptoms suggestive of Acute HIV Infection

XIII. Management: Follow-up

  1. Follow-up weekly during protocol

XIV. Management: Consultation Indications

  1. Treating clinician without experience using these medications or protocols
  2. Delayed exposure report beyond optimal 24-36 hour time frame
  3. Unknown source
  4. Exposed patient is pregnant or lactating
  5. Source patient is known to be resistant to certain Antiretroviral agents
  6. Adverse effects of Antiretroviral agents limiting use

XV. Efficacy

  1. Zidovudine alone: 81% reduction in HIV seroconversion
    1. Zidovudine not used alone anymore due to resistance
    2. Cardo (1997) N Engl J Med 337:1485-90 [PubMed]
  2. No occupational exposure seroconversions since 2001 in U.S., but high risk sexual exposure seroconversion >2%
    1. Post-exposure Prophylaxis is highly effective at preventing seroconversion, but is inconsistently offered
    2. Offer Post-exposure Prophylaxis to BOTH occupational exposed and non-occupational exposed patients
    3. O'Donnell (2016) Ann Emerg Med 68(3):315-23 +PMID:27112264 [PubMed]

XVI. Resources

  1. AIDS.GOV Postexposure Prophylaxis
    1. https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/post-exposure-prophylaxis/
  2. National HIV Clinicians Consultation Center
    1. http://www.nccc.ucsf.edu
    2. Phone (PepLine): 1-888-HIV-4911 or 888-448-4911 (health care providers only)

XVII. Reference

  1. Orman and Moran in Herbert (2016) EM:Rap 16(4):16-7
  2. (2005) MMWR Morb Mortal Wkly Rep 54: (RR-9): 1-17 [PubMed]
  3. (1996) MMWR Morb Mortal Wkly Rep 45:468-72 [PubMed]
  4. (2001) MMWR Morb Mortal Wkly Rep 50(RR-11):24-25 [PubMed]
  5. Kuhar (2013) Infect Control Hosp Epidemiol 34(9):875-92 [PubMed]
  6. Merchant (2000) Ann Emerg Med 36:371 [PubMed]

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