New Federal Guidelines for Managing Occupational Exposures to HIV

Author: SHEA
Date Published:8/6/2013 11:09:00 AM
Publication Format:
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For Immediate Release: August 6, 2013
Society for Healthcare Epidemiology of America
Contact: Tamara Moore / tmoore@gymr.com/ 202-745-5114
Study contact: CDC Press Office/ media@cdc.gov / 404-639-3286

Recommendations consider new drugs and tests

CHICAGO (August 6, 2013) – New guidelines from the United States Public Health Service update the recommendations for the management of healthcare personnel (HCP) with occupational exposure to HIV and use of postexposure prophylaxis (PEP). The guidelines, published online today in Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA), emphasize the immediate use of a PEP regimen containing three or more antiretroviral drugs after any occupational exposure to HIV.

The PEP regimens recommended in the guidelines encourage the consistent use of a combination of three or more drugs, that are better tolerated than those recommended in the previously published guidelines from 2005, for all occupational exposures to HIV. The guidance eliminates the previous recommendation to assess the level of risk associated with individual exposures to help determine the appropriate number of drugs recommended for PEP.

“Preventing exposures should be the leading strategy to prevent occupational HIV infections,” said David Kuhar, MD, an author of the guidelines and medical epidemiologist with the Centers for Disease Control and Prevention’s (CDC) Division of Healthcare Quality Promotion. “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.”

Expert consultation should be sought, but not at the expense of delaying treatment. Exposed HCP taking HIV PEP should complete a full four-week regimen and undergo follow-up HIV testing, monitoring for drug toxicity and counseling, beginning with follow-up appointments within 72 hours of the exposure. If a newer 4th generation HIV antigen/antibody combination test is used for follow-up testing, an option to conclude HIV testing at 4 months, rather than the recommended 6 months after exposure, is provided.  Many of the revised recommendations are intended to make the PEP regimen better tolerated, increasing the possibility that HCP complete the full regimen. 

The guidelines were developed by an interagency Public Health Service working group comprised of representatives from the CDC, National Institutes of Health, Food and Drug Administration and the Health Resources and Services Administration, in consultation with an external expert panel. The updated revisions were based upon expert opinion.

HCP might include emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, environmental maintenance personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students and trainees. Many HCP exposures to HIV occur outside of health clinic hours of operation and initial exposure management is often overseen by emergency physicians or other providers who are not experts in the treatment of HIV infection or the use of antiretroviral medications. As such, the updated guidelines should be distributed and made readily available to emergency physicians and other providers as needed.

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David T. Kuhar, MD; David K. Henderson, MD; Kimberly A. Struble, PharmD; Walid Heneine, PhD; Vasavi Thomas, RPh, MPH; Laura W. Cheever, MD, ScM; Ahmed Gomaa, MD, ScD, MSPH; Adelisa L. Panlilio, MD; for the US Public Health Service Working Group. “Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.” Infection Control and Hospital Epidemiology 34:9 (September 2013).

Published through a partnership between the Society for Healthcare Epidemiology of America and The University of Chicago Press, Infection Control and Hospital Epidemiology provides original, peer-reviewed scientific articles for anyone involved with an infection control or epidemiology program in a hospital or healthcare facility. ICHE is ranked 13 out of 158 journals in its discipline in the latest Web of Knowledge Journal Citation Reports from Thomson Reuters.
SHEA is a professional society representing more than 2,000 physicians and other healthcare professionals around the world with expertise in healthcare epidemiology and infection prevention and control. SHEA's mission is to prevent and control healthcare-associated infections and advance the field of healthcare epidemiology. The society leads this field by promoting science and research and providing high-quality education and training in epidemiologic methods and prevention strategies. SHEA upholds the value and critical contributions of healthcare epidemiology to improving patient care and healthcare worker safety in all healthcare settings. Visit SHEA online at www.shea-online.org, www.facebook.com/SHEApreventingHAIs and @SHEA_Epi.

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HIV Occupational Exposure: USPHS Updates Guidelines

Medscape Medical News

Laurie Barclay, MD

Aug 09, 2013

After any occupational exposure to HIV, healthcare personnel (HCP) should immediately receive a postexposure prophylaxis (PEP) regimen containing at least 3 antiretroviral drugs, according to updated guidelines published in the September issue of Infection Control and Hospital Epidemiology. The current recommendations from the United States Public Health Service (USPHS) update the 2005 guidelines for management of HCP with occupational HIV exposure and use of PEP.

A major change in the recommendation refers to the number of drugs included in the PEP regimen. The previous guidelines recommended evaluating the risk level associated with specific exposures to help determine the optimal number of antiretroviral drugs for PEP. In contrast, the current recommendations call for consistent use of a combination of 3 or more drugs for all occupational exposures to HIV.

"Preventing exposures should be the leading strategy to prevent occupational HIV infections," guidelines author David Kuhar, MD, a medical epidemiologist from the Centers for Disease Control and Prevention's Division of Healthcare Quality Promotion, said in a Society for Healthcare Epidemiology of America news release. "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."

An interagency USPHS working group, including members from the Centers for Disease Control and Prevention, National Institutes of Health, US Food and Drug Administration, and the Health Resources and Services Administration, developed these guidelines with input from an external expert panel.

To improve compliance and completion of the full PEP regimen, many of the revised recommendations aim to improve tolerability of the PEP regimen. Drugs in the currently recommended regimens are better tolerated than those previously recommended.

Specific Recommendations

• The guidelines emphasize primary prevention strategies and prompt reporting and management of occupational exposures.
• If possible, the HIV status of the exposure source patient should be determined to guide the need for HIV PEP.
• Initiating PEP should be the first priority and should not be delayed pending expert consultation, which is also recommended.
• PEP regimens should contain 3 (or more) antiretroviral drugs for 4 weeks.
• Follow-up appointments should begin within 72 hours of HIV exposure and should include follow-up HIV testing, monitoring for drug toxicity, and counselling.
• HIV testing should generally continue for 6 months after exposure.
• HIV testing may be concluded at 4 months, provided a newer fourth-generation HIV antigen/antibody combination test is used for follow-up testing.
• The updated guidelines should be distributed to emergency physicians and other providers as needed, because many HCP exposures occur outside of normal office hours. Emergency physicians or other providers who are not experts in HIV treatment or in the use of antiretroviral therapy medications often oversee initial management of HIV exposure in emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, environmental maintenance personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students, and trainees.

"To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures," the guidelines authors write.

Some of the expert panel consultants report various financial disclosures with Bristol-Myers Squibb, Janssen, Merck, ViiV, Gilead, and GlaxoSmithKline. The other authors have disclosed no relevant financial relationships.

Infect Control Hosp Epidemiol. 2013;34:875-892. Full text

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