A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis Table 11-7. Recommended HIV Postexposure Prophylaxis for Mucous Membrane Exposures and Nonintact Skin ∞ Exposures Infection Status of Sources Exposure Type HIV-Positive Class 1* HIV-Positive Class 2* Source of unknown Unknown source Ø HIV-Negative HIV status + Small Volume Consider basic 2- drug PEP Recommend basic 2-drug PEP Generally, no PEP warranted; however, consider basic 2-drug PEP** for source with HIV risk factors § Generally, no PEP warranted; however, consider basic 2- drug PEP** in settings where exposure to HIV-infected persons is likely No PEP warranted Large Volume † Recommend basic 2-drug PEP Recommend expanded 3-drug PEP Generally, no PEP warranted; however, consider basic 2-drug PEP** for source with HIV risk factors § Generally, no PEP warranted; however, consider basic 2- drug PEP** in settings where exposure to HIV-infected persons is likely No PEP warranted 11 ∞ For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion, or open wound). * HIV-Positive, Class 1 asymptomatic HIV infection or known low viral load (e.g.,
A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis Basic 2-drug PEP 3-drug PEP Table 11-9. Treatment Options for 2- and 3-drug PEP Treatment Options zidovudine (AZT) 300 mg bid + lamivudine (3TC) 150 mg bid (may be taken as Combivir bid) stavudine (d4T) 40 mg bid + 3TC 150 mg bid stavudine (D4T) 40 mg bid + didanosine (ddI) 400 mg qd on an empty stomach (No longer recommended because of increased toxicity unless a suitable alternative is not available.) One of the above NRTI* combinations plus a third drug, usually a PI**, an NTRTI # ,or an NNRTI,*** to be determined in consultation with an HIV expert. nevirapine (NVP) (No longer recommended for PEP due to the potential for severe liver toxicity.) * NRTI: nucleoside or nucleoside reverse transcriptase inhibitor ** PI: protease inhibitor # NTRTI: nucleotide reverse transcriptase inhibitor, i.e., tenofovir (TDF) *** NNRTI: non-nucleoside reverse transcriptase inhibitors, i.e., efavirenz (EFV) should be chosen with the advice of an HIV expert. In accordance with the same principles that are used in treating HIV-positive persons; some experts believe that 3-drug PEP regimens should be the mainstay of PEP and that 2-drug regimens should be used only during extenuating circumstances such as an inability to tolerate a protease inhibitor (PI). For example, the New York State PEP Guidelines now recommend zidovudine and lamivudine (Combivir) plus tenofovir (two pills in the morning and one pill in the evening) as the standard PEP intervention. (http:\\www.hivguidelines.org) Although the current data on PEP for nonoccupational HIV exposures are scant, treatment recommendations for occupational PEP can be generalized to nonoccupationally exposed persons. As in the case of PEP in HCP, nonjudgmental counseling directed towards the reduction of future exposures is an important part of PEP in nonHCP. What are the side effects of HIV PEP? Side effects of HIV PEP regimens are common and occur in 30%-50% of patients. Severe side effects occur in 5%-30% of patients and often require discontinuation. Common side effects include gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain; rash; fatigue; headache and dizziness; cytopenia; neuropathy; hepatitis; and many others. In reported series to date, over half of HCP in PEP programs fail to complete their 28-day regimens because of side effects. Regularly scheduled followup either in person or by phone has been shown to greatly improve adherence. Refer to other chapters for more detail on symptom management and metabolic complications with ART. What medication toxicities should be monitored? Regular laboratory evaluation for medication toxicity and seroconversion should be performed (see Table 11-5). A complete blood count and renal and hepatic function tests should be done before initiating PEP and repeated in 2 weeks. Continued monitoring is recommended for abnormal lab test results, and medication changes should be considered if abnormalities are severe. Specific monitoring parameters vary with the regimen; for example, glucose levels should be monitored if a PI is used. If the PI is indinavir (IDV) a urinalysis should also be checked to monitor for crystalluria and hematuria. Tenofovir (TDF) is well tolerated, but should be used with caution and careful monitoring in patients with compromised renal function (Refer to Drug Information Tables in the Pocket Guide for medication side effects.) Two regimens deserve special consideration. Hepatotoxicity, Stevens-Johnson syndrome, and fatal hepatic necrosis have occurred in HCP treated with nevirapine (NVP) as part of their PEP regimen, and therefore its use is not recommended, given the variety of other options. Pregnant women treated with stavudine (d4T) and didanosine (ddI) were found to be at increased risk for fatal and non-fatal lactic acidosis, and therefore this combination is not recommended in the treatment of pregnant women. In addition, recent clinical trial data showed a higher rate of adverse effects with the combination of stavudine and didanosine in adults, and their use in combination is not recommended unless other alternatives are not available. What are the treatment recommendations when the source patient is known to have specific HIV resistance mutations? Resistance to HIV medications is an important consideration in the treatment of HIV-positive persons, and known resistance in the source patient should be a consideration when choosing an appropriate HIV PEP regimen. In addition, because of reported increases in resistance mutations in recently acquired HIV infection in several cities in the United States, resistance is increasingly a concern in untreated patients, and thus for PEP in exposures to unknown sources. HIV PEP failures attributed to exposure to resistant virus have been reported in the literature. 11 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 91
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