1. Antiretroviral Postexposure Prophylaxis after Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV in the United States Recommendations from the U.S. Department of Health and Human Services January 2005

2. March 2008 AETC National Resource Center, www.aidsetc.org About This Presentation  These slides were developed using the January 2005 recommendations. The intended audience is clinicians involved in the care of patients with HIV.  Users are cautioned that, because of the rapidly changing field of HIV care, this information could become out of date quickly. Finally, it is intended that these slides be used as prepared, without changes in either content or attribution. Users are asked to honor this intent. – AETC NRC http://www.aids-etc.org

3. March 2008 AETC National Resource Center, www.aidsetc.org Evidence of Possible Benefits from nPEP  Animal studies  Postnatal (mother-to-child) prophylaxis  Occupational PEP  Observational studies of nPEP

4. March 2008 AETC National Resource Center, www.aidsetc.org Evidence of Possible Risks from nPEP (2)  Impact on risk-reduction behaviors  ARV side effects and toxicity  Selection of resistant virus

5. March 2008 AETC National Resource Center, www.aidsetc.org Evaluation of Persons Seeking nPEP  HIV status of person seeking nPEP  Perform HIV baseline testing on persons seeking nPEP; use rapid test if possible  Time and frequency of exposure  nPEP is less likely to be effective >72 hours postexposure  nPEP should be used infrequently

6. March 2008 AETC National Resource Center, www.aidsetc.org Evaluation of Persons Seeking nPEP: HIV Status of Source  HIV status of source: HIV positive  Consider nPEP if within 72 hours of exposure  When possible, interview source to determine ARV use and most recent viral load  HIV status of source: Unknown  Determine whether source is available for testing  If source is from group with high prevalence of HIV infection, risk of transmission might be increased  Do not delay initiation of nPEP for source testing

7. March 2008 AETC National Resource Center, www.aidsetc.org Transmission Risk from the Exposure  Determine the specific sexual, injection drug use, or other behavior that led person to seek nPEP (see Estimated Per-Act Risk by Exposure Route)  Determine relative risk for HIV exposure using algorithm for evaluation and treatment and per-act risk for acquisition of HIV

8. March 2008 AETC National Resource Center, www.aidsetc.org Estimated Per-Act Risk for Acquisition of HIV by Exposure Route Exposure RouteRisk per 10,000 exposures Blood transfusion9,000 Needle-sharing injection drug use67 Receptive anal intercourse50 Percutaneous needle stick30 Receptive penile-vaginal intercourse10 Insertive anal intercourse6.5 Insertive penile-vaginal intercourse10 Receptive oral intercourse1 Insertive oral intercourse0.5

9. March 2008 AETC National Resource Center, www.aidsetc.org Recommendations for Use of ARVs for nPEP Negligible exposure risk

10. March 2008 AETC National Resource Center, www.aidsetc.org Assessing Risk of HIV Exposure Negligible Risk of HIV Exposure Exposure of:  vagina, rectum, eye, mouth or other mucous membrane, intact or nonintact skin, or percutaneous contact With:  urine, nasal secretions, saliva, sweat, or tears if not visibly contaminated with blood Regardless of the known or suspected HIV status of the source Substantial Risk of HIV Exposure Exposure of:  vagina, rectum, eye, mouth or other mucous membrane, nonintact skin, or percutaneous contact With:  blood, semen, vaginal secretions, rectal secretions, breast milk, or any body fluid that is visibly contaminated with blood When the source is known to be HIV infected

11. March 2008 AETC National Resource Center, www.aidsetc.org Preferred ARV Regimens for nPEP NNRTI based EFV + (3TC or FTC) + (ZDV or TDF) for 28 days Do not administer EFV to pregnant women PI based LPV/RTV (Kaletra) + (3TC or FTC) + ZDV for 28 days

12. March 2008 AETC National Resource Center, www.aidsetc.org Considerations for All Patients Treated with nPEP  Use starter packs  Clinicians not experienced using ART should consult with ID or other HIV-care specialists  Facilitate adherence  Monitor for signs and symptoms associated with acute infection  Follow-up HIV tests at 4-6 weeks, 3 months, and 6 months to determine whether infection has occurred  Screening for STDs, hepatitis B and C, and pregnancy should be offered  HIV prevention counseling  Reporting and confidentiality

13. March 2008 AETC National Resource Center, www.aidsetc.org Lab Evaluations for nPEP TestBaselineDuring nPEP 4-6 Weeks after Exposure 3 Months after Exposure 6 Months after Exposure HIV antibody E, SEEE Blood count EE Serum liver enzymes EE STDsE,SEE Hep B serology E,SEE E = exposed patient; S = source patient

14. March 2008 AETC National Resource Center, www.aidsetc.org Lab Evaluations for nPEP (2) TestBaselineDuring nPEP 4-6 Weeks after Exposure 3 Months after Exposure 6 Months after Exposure Pregnancy test (for women of reproductive age) EEE HIV viral loadSEEE HIV resistance testing SEEE CD4 countSEEE

15. March 2008 AETC National Resource Center, www.aidsetc.org Special Considerations for Vulnerable Populations  Pregnant women and women of childbearing potential  Children  Sexual assault survivors  Inmates  Injection drug users

16. March 2008 AETC National Resource Center, www.aidsetc.org About This Slide Set  This presentation was prepared by Mark Vogel, MA, for the AETC National Resource Center in January 2005  See the AETC NRC website for the most current version of this presentation: http://www.aids-etc.org