A Practical Approach to Post-Exposure Prophylaxis for HIV and Other Viral Infections

Step 1

a   Establish information on exposure type

1)    Anatomic location of exposure including integrity assessment

(1)   Parenteral: high risk

(2)   Mucosal: splash (lower risk), intraoral (higher risk), rectal deposition (higher risk), vaginal deposition (higher risk)

(3)   Skin: low risk unless integrity impaired (dermatitis, laceration, etc.)

2)    Define / identify sharps type

(1)   Solid bore needle or scalpel: lower risk

(2)   Hollow bore needle or instrument: higher risk

3)    Estimate amount of at risk body fluid exposure via the following

(1)   Visible blood location

(a)    Source patient

(b)    Exposed party

(c)    Both source patient and exposed party (high risk)

(2)   Type of body fluid exposure

(a)   Nonbloody source fluid exposure: urine, CSF, saliva (low risk)

(b)   Bloody body fluid: urine, CSF, saliva (increased risk)

(c)    Frank blood (highest risk)

(d)   Semen or vaginal fluid

b   Establish HIV viral load of source: higher viral load correlates with higher risk of transmission

1)      Known via recent measurement

2)      Estimated if not known

(1)   History of antiretroviral therapy

(2)   Known or suspected resistance profile of source HIV

(3)   Adherence

(4)   Currently on therapy?

Step 2

1)    Complete medical, surgical, sexual, and psychiatric history of exposed party

2)    Exposed person laboratory

(1)   CBC

(2)   CMP

(3)   HIV-1 antibody

(4)   HCV antibody

(5)   RPR

(6)   HBsAg, HBsAb

3)    Source patient laboratory

(1)   HIV antibody if not already done

(2)   HIV viral load

(3)   CD4 lymphocyte count

(4)   HCV antibody

(5)   HBsAg

b    Define resistance mutations of source patient HIV strain

1)    Known via current genotype or phenotype (including most recent date of determination)

2)    Estimated

(1)   History of antiretroviral therapy before and since last resistance testing (if ever done)

(2)   Adherence

(3)   Currently on therapy

3)    Previous resistance testing results if available even in relatively remote past

c     Initiate antiretroviral PEP therapy as soon as possible after exposure, preferably within 1 hour

1)   Duration: 28 days

2)   Antiretroviral drug selection

(1)   Based on likely or known resistance profile of source (see b above): consultation with HIV resistance expert is strongly recommended

(2)   Provide full dosing of at least three active agents

(3)   Avoid nevirapine due to unacceptable risk of hepatotoxicity

3)    Follow up: at 3-5 days and at least weekly

4)    Follow up labs

(1)   Week 1: CBC, CMP

(2)   Week 2: CBC, CMP

(3)   Week 4: CBC, CMP

(4)   Week 6: HIV-Ab, consider HIV viral load

(5)   Week 12: HIV-Ab

(6)   Month 6: HIV-Ab, HCV, HBsAb

(7)   Month 12: HIV-Ab, HCV

d      Initiate PEP for hepatitis B with HBIg and hepatitis B vaccine if source is HBsAg+ and contact is nonimmune