MANAGEMENT

All persons exposed to HIV should receive follow-up counseling and medical evaluation, regardless of whether they receive PEP. The U.S. Public Health Service (PHS) recommends PEP for certain occupational HIV exposures but cannot definitively rec- ommend for or against antiretroviral agents in preventing nonoccupational HIV exposures.

Postexposure prophylaxis should be recommended to exposed HCWs after occupational exposures associated with a known risk for HIV transmission (e.g.,

needlestick injuries to HIV-infected blood), should be considered for exposures with a negligible risk (e.g., mucous membrane exposures to HIV-infected blood), and may not be warranted for exposures that do not pose a known risk for HIV transmission (e.g., intact skin exposures) .

For exposures for which PEP is

considered appropriate, exposed workers should be informed that knowledge about the efficacy and toxicity of drugs used for PEP is limited. Exposed HCWs who choose to take PEP should be advised of the importance of completing the prescribed regimen. They should know the side effects of the drugs that have been prescribed, what can be done to minimize these effects, and how clinical monitoring for toxicity during the follow-up period will be implemented. HCWs who have HIV occupational exposures for which PEP is not recommended should be informed that the potential side effects and toxicity of PEP outweigh the negligible risk of transmission posed by the type of exposure.

Most occupational HIV exposures will warrant only a two-drug regimen, using two nucleoside analog reverse transcriptase inhibitors, usually ZDV and lamivudine. The addition of a third drug, usually a protease inhibitor (e.g., indinavir or nelfinavir), should be considered for exposures that pose an increased risk for transmission or when resistance to the other drugs used for PEP is known or suspected. Over time, new antiretroviral agents will be available for the treatment of HIV infection and may offer increased potency for PEP. The inclusion of new drugs in a PEP regimen should be carried out in consultation with a clinical expert in the treatment of HIV infection.

In general, PEP should be initiated as soon as possible (within hours of the exposure). The interval within which PEP should be started for optimal efficacy is not known. The optimal duration of PEP also is unknown. Because 4 weeks of ZDV appears protective in HCWs, PEP probably should be administered for 4 weeks, if tolerated. When PEP is used, drug toxicity monitoring should include a complete blood count and renal and hepatic chemical function tests at baseline and 2 weeks after starting PEP. The psychological impact of HIV exposure may be considerable and should be addressed during counseling and follow-up. Experts have found that supportive counseling is an important part of management. To prevent the possibility of further transmission to others, the exposed person should be advised to refrain from donating blood, semen, or organs during the follow-up period and to refrain from breast-feeding when safe and effective alternatives are available. To prevent HIV transmission to sexual contacts, all exposed persons should abstain from, or use latex condoms during, sexual intercourse throughout the follow-up period, especially during the first 6 to 12 weeks after the exposure when most HIV-infected persons are expected to seroconvert.

Many of the principles for management of occupational exposures also apply to management of sexual and other nonoccupational HIV exposures, although these instances require the consideration of additional factors. The first step in managing a reported nonoccupational event that may have led to HIV exposure is the determination of the infection status of the reported source. Unlike occupational exposures, the putative source in these cases may not be available to clinicians to provide documentation of HIV status or clinical information on antiretroviral use or viral load. Even in cases where partner notification or timely arrest of assailants (e.g., rape or child abuse) would potentially allow HIV testing of an identified source, delays in seeking care and obtaining test results may necessitate decisions based on estimating the likelihood of infection in the source. If it is determined that the source is, or is likely to be, HIV-infected, the next step is to determine the risk of transmission given the details of the reported exposure. Factors that would either increase (e.g., bleeding and visible mucosal tears in a rape patient) or reduce (e.g., condom used without leak or tear detected) the risk of transmission should be ascertained. If the source is HIV-infected and the exposure event presents an appreciable risk of transmission, it will be important to determine how frequently such exposures occur for a given patient. PEP is not appropriate for persons who frequently put themselves at risk; these patients should be provided or referred urgently for intensive risk reduction intervention.

The use of PEP for nonoccupational exposures should be judicious and only in the context of a comprehensive program of HIV prevention. Results from a program for PEP after nonoccupational exposures in San Francisco, where participants are provided risk reduction counseling in addition to an option to take a 28-day PEP course, have shown that it is possible to provide PEP within 72 hours after exposure and that 80% of persons taking a 4-week PEP regimen completed it.