HIV Postexposure Prophylaxis, Occupational 

Postexposure prophylaxis (PEP) is recommended for health-care personnel who have occupational exposure to blood or other body fluids that may contain human immunodeficiency virus (HIV). ^{[1, 2]} The HIV status of the exposure source patient should be determined, if possible, to guide the need for HIV PEP. PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration. PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV.

An exposure that might place a health care provider at risk for HIV infection is defined as one of the following:

• Percutaneous injury (eg, a needlestick or cut with a sharp object)
• Contact of mucous membrane or nonintact skin (eg, exposed skin that is chapped, abraded, or afflicted with dermatitis)

In addition to blood and visibly bloody body fluids, the following fluids are considered potentially infectious:

• Semen and vaginal secretions
• Cerebrospinal fluid
• Synovial fluid
• Pleural fluid
• Peritoneal fluid
• Pericardial fluid
• Amniotic fluid

Noninfectious exposures

The following are not considered potentially infectious unless they are visibly bloody:

• Feces
• Nasal secretions
• Saliva
• Sputum
• Sweat
• Tears
• Urine
• Vomitus

Treatment recommendations

HIV PEP should be initiated as soon as possible, preferably within hours of exposure. Considerations include the following:

• Although animal studies demonstrate that PEP is likely to be less effective when started more than 72 hours after exposure, the interval after which no benefit is gained from PEP in humans is undefined.

• If PEP initiation is delayed, the likelihood increases that benefits might not outweigh the risks inherent in taking antiretroviral medications.

• Initiating therapy after a longer interval (eg, 1 week) might still be considered for exposures that represent an extremely high risk of transmission.

Because 4 weeks of PEP appeared protective in in vitro, animal, and occupational studies, PEP should be administered for 4 weeks, if tolerated.

Antiretroviral drug regimens

The Public Health Service (PHS) no longer recommends that the severity of exposure be used to determine the number of drugs to be offered in an HIV PEP regimen. Currently, a regimen that contains 3 (or more) antiretroviral drugs is recommended routinely for all occupational HIV exposures.

Examples of recommended PEP regimens include those that consist of a dual nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone plus an integrase strand transfer inhibitor (INSTI), a ritonavir-boosted protease inhibitor (PI), or a nonnucleoside reverse transcriptase inhibitor (NNRTI). ^[5]

Preferred regimen

• Raltegravir plus tenofovir/emtricitabine ^{[3, 4]}
• Raltegravir (400 mg) is given twice daily; enofovir/emtricitabine (300 mg/200 mg) is given once daily

Alternative regimens

Alternative regimens may combine 1 drug or drug pair from the INSTI, PI, or NNRTI classes with 1 pair of NRTIs listed below.

INSTI, PI, or NNRTI options include the following:

• Raltegravir
• Darunavir plus ritonavir
• Etravirine
• Rilpivirine
• Atazanavir plus ritonavir
• Lopinavir/ritonavir

NRTIs combined with agent(s) selected above include the following:

• Tenofovir/emtricitabine
• Tenofovir plus lamivudine
• Zidovudine/lamivudine
• Zidovudine plus emtricitabine

Alternative antiretroviral agents for use as PEP only with expert consultation include the following:

• Abacavir
• Efavirenz
• Enfuvirtide
• Fosamprenavir
• Maraviroc
• Saquinavir
• Stavudine

The following antiretroviral agents are generally not recommended for use as PEP:

• Didanosine
• Nelfinavir
• Tipranavir

The following antiretroviral agent is contraindicated as PEP:

• Nevirapine