|
|
| Table 1: Recommended PEP for
percutaneous injuries |
| Exposure type |
Infection status of source patient
|
| HIV-positive Asymptomatic |
HIV-positive Symptomatic |
Unknown HIV status |
Unknown source* |
| Less severe |
Recommend basic 2-drug PEP |
Recommend expanded 3-drug PEP |
Generally, no PEP required. Consider basic
2-drug PEP for source with HIV risk factors |
Generally, no PEP
required. Consider basic 2-drug
PEP in settings
where exposure
to HIV- infected
persons is likely |
| More severe |
Recommend expanded 3-drug PEP |
Recommend expanded 3-drug PEP |
Generally, no PEP required. Consider basic
2-drug PEP for source with HIV risk factors |
Generally, no PEP
required. Consider
basic 2-drug PEP
in settings where
exposure to HIV-
infected persons is likely |
| * Unknown source (e.g. a needle from a sharps
disposal container) |
|
| |
| Table 2: Recommended PEP for
mucous membrane exposures and non-intact skin exposures |
| Exposure type |
Infection status of source patient
|
| HIV-positive Asymptomatic |
HIV-positive Symptomatic |
Unknown HIV status |
Unknown source* |
| Small Volume |
Consider basic 2-drug PEP |
Recommend basic 3-drug PEP |
Generally, no PEP required. Consider basic
2-drug PEP for source with HIV risk factors |
Generally, no PEP
required. Consider basic 2-drug
PEP in settings
where exposure
to HIV- infected
persons is likely |
| Large Volume |
Recommend basic 2-drug PEP |
Recommend expanded 3-drug PEP |
Generally, no PEP required. Consider basic
2-drug PEP for source with HIV risk factors |
Generally, no PEP
required. Consider
basic 2-drug PEP
in settings where
exposure to HIV-
infected persons is likely |
| * Unknown source (e.g. splash from inappropriately
disposed blood) |
|
| |
| Table 3 lists the drugs used
for the Basic and Expanded regomens. The duration of therapy for
both the regimens is 4 weeks. |
| Table 3: Basic and Expanded
regimens for PEP |
| Type |
Drugs |
| Basic (28 days) |
Zidovudine 300 mg tid + lamivudine 150 mg
bid
(Duovir) or Stavudine 30-40 mg bid + lamivudine
150 mg bid (Lamivir-S)
|
| Expanded (28 days) |
As above, plus Indinavir (Indivan) 800 mg
8 hourly or Efavirenz (Efavir) 600 mg od at bedtime or Nelfinavir
750 mg tid
|
|
| In case the exposed HCP is pregnant,
the potential effect of antiretrovirals on the pregnant woman
and on her foetus need to be considered. |
| |
| What is the efficacy of PEP regimens
? |
Studies conducted in animals
and in humans prove the efficacy of PEP regimens. Zidovudine has
been the most widely studied agent for prophylaxis. A retrospective
study of HCP who used zidovudine as PEP found that the risk of
HIV infection was reduced by approximately 81%.
Although the efficacy of combination regimens for PEP is unknown,
combination drug regimens are currently recommended for PEP. This
is because they are more potent and may be more effective against
drug-resistant strains.
|
| What are the possible side-effects
of PEP ? |
Data indicate that nearly 50%
of HCP experience adverse symptoms while taking PEP and that approximately
33% stop taking PEP because of adverse effects. HCP who are given
PEP need to be monitored for drug toxicity at baseline (on starting
PEP), and two weeks after therapy begins. Minimally, laboratory
monitoring for toxicity should include a complete blood count
and renal and hepatic function tests.
Information should be provided to the HCP about potential drug
interactions and the drugs that should not be taken with PEP,
the side effects of the drugs that have been prescribed, measures
to minimize these effects, and the methods of clinical monitoring
for toxicity during the follow-up period. HCP should be advised
that the evaluation of certain symptoms should not be delayed
(e.g. rash, fever, back or abdominal pain, pain or urination or
blood in the urine, or symptoms of hyperglycemia).
|
| What additional advice should
the exposed HCP be given ? |
|
Exposed HCP should avoid behaviours that carry a risk of secondary
transmission of HIV for the duration of the follow-up period.
This is especially true for the first 6 to 12 weeks after exposure,
when seroconversion is most likely to occur.
The exposed HCP should be advised on the following:
- Sexual abstinence
- Use of condoms to prevent sexual transmission and pregnancy
- Not to donate blood, plasma, organs, tissue or semen
- HIV and some drugs used in therapy can pass through breast
milk. Consider discontinuing breast-feeding, particularly
after high-risk exposures.
|
| Conclusion |
Occupationally acquired HIV
infection represents a health hazard for HCP caring for HIV-positive
patients. Although the risk of transmission is low, it is important
to institute measures to reduce such risks, as also establish
protocols for treating exposed HCP.
Current guidelines recommend commencing prophylactic two- or three-drug
regimens immediately after an exposure which poses a risk of transmitting
HIV infection. |
| References |
|
1. Consultant Jan 1999, p 230-36.
2. MMWR May 15, 1998, Vol 47, No. RR-7.
3. Fahrner R. Risk of HIV in HCWs. In: AIDS Clinical Review
2000/2001 Volberding PA, Jacobson MA, Eds. Marcel Dekker Inc,
2001.
4. MMWR June 29, 2001 Vol 50, No RR-II.
|
