Updated guidelines issued for occupational PEP use

PEP regimens have changed

The U.S. Public Health Service has changed its treatment guidelines for the use of postexposure prophylaxis (PEP), following an occupational exposure to HIV infection.

The new guidelines advise clinicians to consider occupational exposures as urgent medical concerns, and to ensure timely postexposure management and administration of HIV PEP.1

The list of antiretroviral medications that should be considered for PEP use has been expanded and modified. There now are five classes of HIV antiretrovirals on the PEP list, including the fusion inhibitor enfuvirtide (Fuzeon) and the nucleotide analogue reverse transcriptase inhibitor (NtRTI) tenofovir (Viread, TDF).1

Included on the expanded PEP list are five nucleoside reverse transcriptase inhibitors (NRTIs), seven protease inhibitors (PIs), and efavirenz (Sustiva), a non-nucleoside reverse transcriptase inhibitor (NNRTI).1

Treatment guidelines state that people receiving PEP should complete a full four-week regimen, although clinicians should select the treatment while considering adverse events and toxicity profiles of the agents. Anecdotal evidence has shown that health care personnel taking HIV PEP have high rates of non-completion of therapy because of an inability to tolerate the drugs.1

Data from the National Surveillance System for Health Care Workers show that about 47 percent of 921 health care persons with at least one follow-up visit after starting PEP experienced one or more symptoms, including nausea, malaise and fatigue.1

The guidelines note that there is little evidence of what would be the best PEP to recommend, although a combination of drugs with activity at different stages in the viral replication process, such as a nucleoside analogue with a PI, theoretically might offer additive preventive effect.1

Also, the guidelines suggest that offering a two-drug regimen might be a viable option because such a combination might decrease the risk of a person stopping the treatment before completion.1

From June 1995 to December 2004, there were 28,010 exposures to blood and body fluids reported by 95 U.S. hospitals in a convenience sample, according to 2005 data from the Centers for Disease Control and Prevention (CDC) of Atlanta, GA.1

For the 25,510 with known sources, 1,350 or 5.4 percent were to HIV-positive sources, and 8,859 or 34.7 percent were to sources with unknown HIV status.1

Of these health care workers, 788 started PEP and 317 took PEP for 21 or more days, with the median duration of HIV PEP after exposure of 27 days.1

The guidelines recommend that PEP regimens be PI-based, preferably with lopinavir/ritonavir, and efavirenz might be considered for expanded PEP regimens, especially when resistance to PIs in the source person’s virus is known or suspected.1

Reference

  1. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. MMWR Morb Mortal Wkly Rep. 2005;54(RR-9):1-17.