New federal guidelines for managing occupational exposures to HIV 2013

When the Centers for Disease Control, Food and Drug Administration, National Institutes of Health, and Health Resources and Service Administration get together with an external expert panel you know you got a fantastic group of incredible minds putting it all together for the health of the nation.

This interagency USA Public Health Services working group did just this as it updated the guidelines for Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Post-exposure Prophylaxis.(1)

This document is aimed at Health Care Professionals that have the potential of exposure including but not limited to: emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, environmental maintenance personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students, and trainees.

“Preventing exposures should be the leading strategy to prevent occupational HIV infections; however, when an exposure occurs, it should be considered an urgent medical concern and a PEP regimen should be started right away, ideally within hours of the potential exposure,” stated David Kuhar, MD, one of the authors of the guidelines and medical epidemiologist with the CDC Division of Healthcare Quality Promotion.

A lot of the revisions are intended to make the PEP regimen easer to following and increase compliance. For example if the fourth generation HIV antigen/antibody combination test is used for follow-up testing, an option to conclude HIV testing at four months, rather than the recommended 6 months after exposure utilized.

If an exposure does occur, this document reminds us all how important it is in the medical setting being prepared. The poster campaign (http://www.cdc.gov/hai/pdfs/HIV/HIVPEPinfographicFINAL.pdf) states, “The clock is ticking, take action” this poster gives HCP the steps to take to get immediate appropriate treatment. They emphasize the immediate use of a PEP regimen.

The simple steps that the poster reminds us about are:

Take ACTION right away. Post exposure prophylaxis, medicine you take before you get sick, is recommended for health-care personnel potentially exposed to HIV. PEP should be initiated as soon as possible, within hours of exposure.

1. Get evaluated
• Follow your facility’s procedure for reporting your exposure. Consult an expert for any occupational exposure to HIV. Don’t delay the start of HIV PEP while waiting for an expert consultation.

2. Complete a full course of PEP
• Using three or more PEP drugs at one time. Four-week course. Finish the entire four-week course. The newer recommended HIV PEP drugs are safer and have fewer side effects, making it easier to complete the entire PEP course. Return for evaluation to seek another treatment option if you cannot tolerate PEP.

3. Follow-up
• Follow-up appointments should begin within 72 hours of an HIV exposure. Follow-up should include counseling, baseline and follow-up post-PEP HIV testing, and monitoring for drug toxicity. Follow-up HIV testing can be completed earlier than six months. If a newer fourth-generation combination HIV p24 antigen-HIV antibody test is used for follow-up testing, testing may be concluded at 4 months after exposure. If a newer testing platform is not available, follow-up testing is typically concluded at six months after exposure.

One problem with exposure is it may occur outside of the hours of normal business or when a clinic is closed that the office uses for referral to an expert. Referral to the emergency room or a provider that is not aware of the protocols and procedures in the treatment of HIV infection or the use of antiretroviral medications could potentially put the HCP at risk. The updated guidelines will be distributed and made readily available to emergency physicians and other providers as needed eliminating this risk.

One of the major changes in the guidelines from 2005 is the use of risk level assessment in determining the number of drugs that will be used for PEP is no longer recommended. The document stresses that PEP containing three or more antiretroviral drugs after any occupational exposure to HIV should be used immediately. These drugs have been found to be easier on the exposed individual than the drugs that were used in the previous guidelines from 2005 for occupational exposure.

Though an expert consultation should be used, it should never create delay in treatment. Any time an exposure has occurred, treatment should begin immediately. The HCP that has had exposure should have a complete four week regimen, and this should be follow up with appointments including: HIV testing, monitoring for drug toxicity, and--importantly--counseling. Follow up should start within 72 hours of exposure.

These resources were developed to help keep HCP safe. Making the entire HCP team aware of the guidelines could be the difference between life and death.

References
1. “Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Post-exposure Prophylaxis.” Infection Control and Hospital Epidemiology 34:9 (September 2013).

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