August 7th, 2013

Occupational Post-Exposure Prophylaxis (PEP) Guidelines Updated — And They Are Clear and Sensible

Sharks have the longest gestation periodGood 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Authored by an expert panel, these updated occupational PEP guidelines replace the (woefully outdated, sorry, had to write that) previous version, which dates back to 2005.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 …

5 Responses to “Occupational Post-Exposure Prophylaxis (PEP) Guidelines Updated — And They Are Clear and Sensible”

  1. Chiaying Liu, MD says:

    It’s a great news to have an updated guideline for prophylactic regimen of the occupational exposure.

    The relatively safe adverse profiles of RAL/TDF/FTC make this regimen as the preferred one. However, considering the recent data regarding the clinical efficacy of EVG/c/TDF/FTC and convenience, is it possible to replace the current recommendation to this single pill regimen in the near future? According to my previous experiences, the healthcare workers frequently missed some doses of the twice daily regimen because of their frequent day/night shifting. The lower threshold of RAL remained a concern. Sometimes, a boosted PI with Truvada seems to be a good option if compliance is concerned, but the side effects of Lopinavir/r also compromise the overall compliance. Maybe EVG/c/TDF/FTC would be a possible solution?

    • Paul Sax says:

      Maybe EVG/c/TDF/FTC would be a possible solution?

      Agree, it’s likely to be easier to take — glad it’s listed as an alternative. The downside, of course, is the potential for drug-drug interactions.


  2. TE says:

    Was disappointed that they didn’t recommend decreasing the total f/u to 3 months (see Australasian PEP guidelines) and interested that they now recommend 3 drugs v no drugs. We’ve talked about this for a while. I wonder if this will change our practice on the pts who we would be comfortable following off meds but they insist on taking something. Will we now give them 3 meds? I don’t think I will. The Australasian guidelines also recommend checking a CPK at 2 wks in pts on Raltegravir. Do you think that is reasonable or overkill?

  3. Chiaying Liu, MD says:

    I guess the downside of this single pill combination would be its nephrotoxicity. We still do not have enough data for the prolonged use of EVG/c, especially when we used it with TDF/FTC. For PEP users, the relatively short-term use may not be associated with clinically significant events. For those longterm users or healthcare workers with CKDs, we would need further information to clarify the longterm adverse events.

  4. paula proenca says:

    I would like to know if the recomendation for PEP is the same for an exposure to HIV2 ( non complaint patient on truvada kaletra, the surgeon get a needle stick while doing appendicectomy).

    thank you
    Faro Hospital

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.