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August 7th, 2013
Occupational Post-Exposure Prophylaxis (PEP) Guidelines Updated — And They Are Clear and Sensible
Good news here — the United States Public Health Service has issued new national guidelines for management of occupational exposure to HIV.
Authored by an expert panel, these updated occupational PEP guidelines replace the (woefully outdated, sorry, had to write that) previous version, which dates back to 2005.
On a quick read-through, despite the density of print, the new guidelines are excellent and sensible, providing much needed clarity to an often confusing and anxiety-provoking clinical situation. They are quite similar to the NY State Guidelines, which have acted as a nice guidance as we awaited these national recommendations.
Here are some of the key recommendations.
- Clinicians may use any validated testing options for evaluating the HIV status of the source patient. This includes point-of-care rapid tests.
- No need to rule out “window period” in the source patient unless acute HIV is suspected clinically. Good to see this explicitly stated.
- PEP regimen of choice: TDF/FTC plus raltegravir for 4 weeks. Many alternative regimens are listed, including the single-pill TDF/FTC/EVG/c combination, which may be useful for non-compliant patients provided there are no significant drug-drug interactions. Full details here.
- No recommendation to use two drugs for lower-risk exposures — it’s all or nothing.
- Expert consultation recommended in several scenarios — for example, delayed (>72 hours) report of exposure, needle stick of unknown source, possible HIV resistance in source patient, pregnancy or severe illness in exposed patient. However, seeking expert consultation should not delay starting PEP.
- The follow-up period for exposed individual can be shortened to 4 months (from 6) if a 4th generation combination HIV p24 antigen/antibody test is used. There isn’t a single exposed health care provider who wouldn’t want this shorter follow-up option.
I especially like this last point — this will greatly decrease the period of anxiety in those exposed! Hope these guidelines provide motivation for hospital labs to update to their HIV screening assays to the 4th generation tests, if they have not done so already.
Now about that gestation period of these guidelines …