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Occupational Postexposure Prophylaxis Guidelines, Updated

Guideline Watch |
August 9, 2013

Occupational Postexposure Prophylaxis Guidelines, Updated

  1. Paul E. Sax, MD

The United States Public Health Service has just issued updated guidelines for management of occupational exposure to HIV.

  1. Paul E. Sax, MD

In August 2013, the U.S. Public Health Service updated its national guidelines for occupational postexposure prophylaxis (PEP). Authored by an expert panel, these guidelines replace the previous version, which dates back to 2005.

Key recommendations include the following:

  • Clinicians may use any validated testing options, including point-of-care rapid tests, for evaluating the HIV status of the source patient. Initiation of PEP should not be delayed while waiting for test results.

  • There is no need to rule out the “window period” in the source patient unless acute HIV infection is suspected clinically.

  • The PEP regimen of choice is tenofovir/FTC plus raltegravir for 4 weeks. Many alternative regimens are listed, including the single-pill tenofovir/FTC/elvitegravir/cobicistat combination. Assuming the absence of serious drug–drug interactions, the latter could be useful for patients who might struggle with a twice-daily regimen.

  • Two-drug regimens are no longer recommended for lower-risk exposures — regimens containing three or more antiretrovirals are now routinely recommended for all occupational HIV exposures.

  • Expert consultation is recommended in several scenarios — for example, if the exposure report is delayed >72 hours; the source patient is unknown (e.g., stick from a needle in a sharps-disposal container or the laundry); drug-resistant HIV is known or suspected in the source patient; or the exposed person is pregnant, breast-feeding, or seriously ill. However, seeking expert consultation should not delay timely initiation of PEP.

  • The follow-up period for exposed individuals can be shortened to 4 months (from 6) if a fourth-generation combination HIV p24 antigen/antibody test is used.

Comment

These long-anticipated updated guidelines are excellent and sensible, providing much-needed clarity to an often confusing and anxiety-provoking clinical situation. I hope that they provide motivation for hospital laboratories to update their HIV screening assays to the fourth-generation tests, if they have not already done so. A shorter follow-up would greatly decrease the period of anxiety in individuals who have been exposed.

  • Disclosures for Paul E. Sax, MD at time of publication Consultant / Advisory board Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Janssen; Merck Grant / research support NIH; Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Merck Editorial boards Medscape; UpToDate Leadership positions in professional societies Mass ID Society (Vice President)

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