Post exposure prophylaxis

Post-Exposure Prophylaxis (PEP) means providing immunoglobulin or sometimes vaccine to a person who has been exposed to an infectious agent, in an effort to prevent them developing the disease. In HIV post-exposure prophylaxis means taking antiretroviral medicines (ART) after being potentially exposed to HIV to prevent becoming infected. Every hour counts.

HIV Post-Exposure Prophylaxis (PEP) should be used only in emergency situations and must be started within 72 hours after a recent possible exposure to HIV. If you think you’ve recently been exposed to HIV during sex or through sharing needles and works to prepare drugs or if you’ve been sexually assaulted, talk to your health care provider or an emergency room doctor about Post-Exposure Prophylaxis (PEP) right away.

If you’re prescribed Post-Exposure Prophylaxis (PEP), you’ll need to take it once or twice daily for 28 days. Post-Exposure Prophylaxis (PEP) is effective in preventing HIV when administered correctly, but not 100%.

Get rapid, expert guidance in managing healthcare worker exposures to HIV and hepatitis B and C, including recommendations on when and how to initiate Post-Exposure Prophylaxis (PEP) through an online Quick Guide (http://nccc.ucsf.edu/clinical-resources/pep-resources/pep-quick-guide-for-occupational-exposures/) for urgent occupational Post-Exposure Prophylaxis (PEP) decision-making, or from experienced clinicians on a telephone consultation service (http://nccc.ucsf.edu/clinician-consultation/).

Prophylactic treatment for needle sticks

Needlestick injuries are known to occur frequently in healthcare settings and can be serious. In North America, millions of healthcare workers use needles in their daily work, and hence, the risk of needlestick injuries is always a concern. Almost any microorganism can be transmitted following a needle stick injury, but practically only a handful of organisms are of clinical concern. The most important organisms that can be acquired after a needlestick injury include human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) ¹. All these three viruses can be acquired by a percutaneous needlestick or splashing of blood on the mucosal surfaces of the body. While HIV primarily affects the immune system, both hepatitis B and C have a predilection for the liver. Tetanus should always be considered when a needlestick injury has occurred, and the patient’s vaccination history must be obtained ².

Despite the high number of needle sticks that occur in healthcare settings, the majority of healthcare workers do not develop any infection. Even if the skin is punctured or there is a spill in the mucous membranes, the majority of individuals do not acquire any organisms. There has always been a concern that healthcare workers are at very high risk of developing disease following a needlestick, but the data do not support this belief. The risk of a healthcare profession for developing any infection depends on the type of needle, the severity of the injury, type of organism in the patient’s blood, and prior vaccination status. Finally, one major determining factor whether an infection will develop is the availability of Post-Exposure Prophylaxis (PEP) ³.

Once a needle stick injury occurs, all healthcare workers need to follow up with the local Occupational Health and Safety Clinic within 12 to 72 hours. During the workup, the individual must be asked to abstain from sexual intercourse until the HIV testing is negative. In fact, most infectious disease experts recommend safe sex or no sex until the second confirmatory HIV test is also negative, which is usually 4 to 6 months. If the initial workup is negative, then the individual needs to be followed up at 2 and 6 months. For those individuals who develop an infection following a needlestick injury, the prognosis is the same as if they had acquired the organism via any other route ⁴.

Immediately after the needle stick injury

Suggestions include:

• Wash the wound with soap and water.
• If soap and water aren’t available, use alcohol-based hand rubs or solutions.
• If you are at work, notify your supervisor or occupational health and safety officer – you will need to fill out an accident report form.
• Go straight to your doctor, or to the nearest hospital emergency department.

Your doctor or the emergency doctor should:

• Take detailed information about the injury, including how long ago it happened, how deeply the skin was penetrated, whether or not the needle was visibly contaminated with blood, and any first aid measures used.
• Explain the transmission risks, which are small.
• Offer blood tests to check for pre-existing human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV). You should be offered counseling about these tests before the blood specimens are taken.
• Inform the original user of the needle about the needlestick injury – if they are known. They will be asked to consent to blood tests to check their HIV, HBV and HCV status. They should be provided with counseling before the tests are done.
• Advise you about reducing the risk of transmission until the test results are received. You should practice safe sex and avoid donating blood.

Ask your doctor about additional counseling if you think that you will require it.

Viral Hepatitis

Of the viruses, the most common organism acquired via a needle stick injury is hepatitis B. About 30% to 50% of individuals who do contract hepatitis B may develop jaundice, fever, nausea, and vague abdominal pain. In most individuals, these symptoms will spontaneously subside in 4 to 8 weeks. About 2% to 5% of the individuals will go on to develop chronic infection with hepatitis B. Over a lifetime, there is a 15% risk that these individuals will develop liver cancer or cirrhosis. Twenty years ago in 1997, data from the Centers for Disease Control and Prevention (CDC) National Hepatitis Surveillance revealed that there were nearly 500 healthcare workers who acquired hepatitis B from a needlestick injury. This was a significant decline from the previously high 17,000 new cases diagnosed in 1983. A report done in 2009 reported that there were 1550 hepatitis B cases from occupational exposure, of which only 13 were related to employment in a healthcare field with exposure to blood. This decline has chiefly been attributed to the universal availability of the hepatitis B vaccine and application of universal precautions. Before the availability of the hepatitis B vaccine, the infection rate from a needlestick ranged from 6% to 30%.

The management of an individual who has acquired hepatitis B following a needlestick injury depends on the recipient’s vaccination status. Today, hepatitis B virus immunoglobulin is available but is not recommended until serological data are obtained. In individuals who have not been vaccinated, hepatitis B immunoglobulin can prevent a full-blown infection. If the person is already infected, the immunoglobulin has been shown to produce a much milder infection. For hepatitis B immunoglobulin to be effective, it needs to be administered within the first 24 hours after exposure. It is used in combination with active immunization.

In Individuals who are not vaccinated and suffer a needlestick injury, the rapid protocol for hepatitis B vaccine is undertaken which involves intramuscular injections at times 0, 1, and 2 months followed by a booster shot at 12 months ².

Hepatitis C post-exposure prophylaxis

After a needle stick injury, healthcare professionals are also at risk for acquiring hepatitis C. Unfortunately the exact number of healthcare workers who have developed hepatitis C after a needle stick injury remains unknown, because of lack of follow up. The risk of hepatitis C virus (HCV) transmission after percutaneous exposure is about 1 in 56 (1.8%) when the source person is hepatitis C-infected. There is no post-exposure prophylaxis currently available/approved for hepatitis C virus prevention ⁵.

After a needlestick or sharps exposure to anti-HCV positive blood, a recent report of data from more than 1,300 potentially exposed health care personnel estimated the risk of hepatitis C infection as approximately 0.2% for percutaneous injuries and 0% for mucocutaneous exposures ⁶. A range of 0-10% has been reported in earlier studies ⁷; variability may be in part explained by mechanism of injury and HCV RNA status of anti-HCV positive sources. If the health care personnel does become infected, follow updated guidelines from the American Association for the Study of Liver Disease (AASLD) and the Infectious Diseases Society of America (IDSA) (https://www.hcvguidelines.org/) for management and treatment of hepatitis C.

After a needlestick injury, most people do not have symptoms from hepatitis C, or if they do develop symptoms, they are vague and may resemble a flu-like syndrome. Unlike hepatitis B virus, where less than 6% of adults develop a chronic infection, with hepatitis C more than 75% of adults will develop a chronic infection. About three-quarter of patients will develop the acute liver disease, and of these, about 20% will go on to develop end-stage liver disease or cirrhosis. About 1% to 5% of them will develop hepatocellular cancer over the next 2 to 3 decades. While there is no post-exposure treatment for hepatitis C, there are some newer drugs that have shown promise in preventing the progression of the liver damage and lowering the rates of liver cancer ⁸.

After review of available studies, guidelines and summary documents, the Clinician Consultation Center PEPline recommends the following approach ⁵:

Table 1. Testing recommendations for the hepatitis C virus (HCV) exposed person

PEPline 2017	Hepatitis C positive source person [1] or Source person has potential HCV risk factors [1]	HCV Ab [2]	6 weeks [3] HCV RNA (HCV viral load)	≥6 months [4][5] HCV Ab [2]
	Source person HCV status unknown [1] or Source person is known and has no known HCV risk factors [1]		Optional: 6 week HCV RNA
CDC 2016 [6]	All source persons [1]	HCV Ab [2]	≥3 weeks HCV RNA	Optional: ≥6 month HCV Ab [2]
CDC 2001 [7]		HCV Ab and ALT	If earlier diagnosis desired: HCV RNA at 4-6 weeks	4-6 months HCV Ab and ALT

Abbreviations: HCV = hepatitis C virus; Ab = antibody; ALT = aminotransferase

Footnotes:

1. For purposes of initial post-exposure management, a source person is considered HCV-positive if either HCV RNA (HCV viral load) or HCV antibody is positive. HCV RNA, when performed on the SP within a few days of the exposure, is the more accurate indicator of infectivity. For the purpose of deciding whether the source can potentially transmit HCV, HCV antibody can be obtained. Positive HCV antibody, however does not always indicate infectivity because: some patients eradicate HCV naturally but retain HCV antibody; and those with active HCV infection can have fluctuating HCV RNA (viral load) as well as undetectable viral load (and are presumably un-infectious at that time when viral load was undetectable).
2. If HCV antibody is positive at any point, follow-up HCV RNA testing is required. Persons with confirmed positive HCV RNA results should be referred for further evaluation and care.
3. The PEPline recommends initial HCV follow-up test at 6 weeks, to coincide with the first HIV follow-up test. There are no data that establish a clinical advantage to testing at 3 weeks vs. 6 weeks [Glynn, et al, Busch, et al, Hajarizadeh, et al]. HCV RNA becomes detectable beginning at 3 weeks. Testing earlier than 6 weeks can be performed at the discretion of the managing clinician, especially if preliminary assessment is needed. Positive HCV RNA indicates likely infection. However, approximately 25% of new infections will clear spontaneously ⁹. Refer to an experienced provider for additional counseling, testing, and follow-up if positive.
4. In HCV infection, HCV RNA can be transiently undetectable ¹⁰. Additionally, HCV antibodies develop slowly. Therefore, even though an early initial negative HCV RNA can be preliminarily reassuring, the PEPline recommends further HCV antibody testing at 6 months (24 weeks) post-exposure to confirm transmission did not occur.
5. An interval (i.e. 12-16 week) HCV antibody test may provide some reassurance for exposed persons in many instances (and align with HIV surveillance). However: (a) testing at this time point may not impact overall exposure management significantly, and (b) it is not sufficiently sensitive to completely exclude HCV transmission. Even at 15 weeks, only about 80% of HCV-infected persons will have positive HCV Ab ¹¹. Therefore, the 6 month (24-week) HCV antibody test is considered to be conclusive in excluding HCV acquisition: ≥97% will be positive at 6 months post exposure ¹¹.
6. Hepatitis C Questions and Answers for Health Professionals (https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm)
7. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR 2001; 50 (RR11): 1-42.

Note regarding exposed persons with symptoms: Symptoms of a viral illness compatible with acute HCV at any point up to 6 months post-exposure should prompt immediate evaluation.

Note regarding availability and feasibility of HCV RNA testing: HCV RNA testing might not be available or feasible at all institutions. If it is not possible to obtain the recommended HCV RNA testing, surveillance using antibody testing is essential in assessing HCV transmission.

Note regarding hepatic enzyme testing: The PEPline does not recommend routine liver enzyme testing for follow-up because of the possibility of abnormal results from causes other than HCV.

Other than needlesticks, do other exposures, such as splashes to the eye, pose a risk to health care personnel for hepatitis C virus transmission?

Although a few cases of hepatitis C virus transmission via blood splash to the eye have been reported, the risk for such transmission is expected to be very low. Avoiding occupational exposure to blood is the primary way to prevent transmission of bloodborne illnesses among health care personnel. All health care personnel should adhere to Standard Precautions. Depending on the medical procedure involved, Standard Precautions may include the appropriate use of personal protective equipment (e.g., gloves, masks, and protective eyewear).

Should hepatitis C virus-infected health care personnel be restricted in their work?

There are no CDC recommendations to restrict a health care worker who is infected with hepatitis C virus. The risk of transmission from an infected health care worker to a patient appears to be very low. All health care personnel, including those who are hepatitis C virus positive, should follow a strict aseptic technique and Standard Precautions, including appropriate hand hygiene, use of protective barriers, and safe injection practices.

What is the recommended management of a health care worker with occupational exposure to hepatitis C virus?

Post-exposure prophylaxis (PEP) for hepatitis C is not recommended, as outlined in the 2001 MMWR on management of health-care personnel who have occupational exposure to blood and other body fluids ⁷. Test the source for HCV RNA. If the source is HCV RNA positive, or if HCV infection status is unknown, follow the above guidance.

After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is 0.1% ⁶. If the health care worker does become infected, follow AASLD/IDSA guidelines for management and treatment of hepatitis C (https://www.hcvguidelines.org/).

Hepatitis B virus post-exposure prophylaxis

After exposure to hepatitis B virus (HBV), appropriate and timely prophylaxis can prevent hepatitis B virus infection and subsequent development of chronic infection or liver disease. The mainstay of post-exposure prophylaxis is hepatitis B vaccine, but, in certain circumstances, hepatitis B immune globulin is recommended in addition to vaccine for added protection.

The following 3 options are available for hepatitis B vaccine in healthcare workers who already have been vaccinated:

1. If the patient is HBsAg positive, the recipient’s serology must be assessed. If the post-vaccination anti-HBs level is high (greater than 10 mIU/mL), this is known to be protective, and there is no need for further treatment, and a booster shot is not recommended. However, if the post-vaccination anti-HBs titer is low or if there is no hepatitis B vaccine available, the healthcare worker should be administered hepatitis B immunoglobulin.
2. If the patient is HBsAg negative, the healthcare workers should be observed, and his or her anti-HBs levels should be monitored
3. If the patient has been discharged or not available for testing, this requires a significant amount of clinical judgment. Most infectious disease experts treat such cases as if the source was HBsAg negative unless the source has a high risk for HBV infection (such as current or former IV drug use). In this case, the assumption is made that the patient is HBsAg positive, and Post-exposure prophylaxis is initiated.

If the healthcare worker is not vaccinated against hepatitis B, then these are the following 3 options:

1. If the patient is HBsAg positive, the healthcare workers should be administered HBV immunoglobulin immediately, followed by a rapid course of active immunization starting 14 days later.
2. If the patient is HBsAg negative, then there is no need to administer hepatitis B immunoglobulin; however, the healthcare worker should strongly be recommended to get the Hepatitis B vaccine.
3. If the patient is not available for testing, then the healthcare workers should be managed as if he or she is HBsAg negative. If there is any suspicion about the patient’s clinical status, for example, if the patient had been admitted for a complication of intravenous drug abuse or had risk factors for hepatitis B, then the healthcare workers must be offered Hepatitis B immunoglobulin, and active vaccination should be recommended in 14 days time. According to the CDC, vaccination should be initiated if the exposed person is unvaccinated, and treatment with HBV immunoglobulin should be initiated if the source person is in a high-risk category ¹².

HIV

HIV infection is a systemic disorder that primarily suppresses the immune system. Over time, almost every organ in the body is involved leading to a variety of symptoms. The virus has an affinity for the CD4 cells, leaving the body in a state of immunosuppression. This leads to the development of opportunistic infections, cancer, and severe wasting. Many patients will go on to develop AIDs. Luckily today Highly Active Antiretroviral Therapy (HAART) is available, and for those who remain compliant with the medication regimens, death is now a rare occurrence. In fact, most people go on to lead a normal life, but HIV is never cured.

However, after a needlestick injury developing HIV is not common at all. In fact, from 1981 to 2010, there have only been 143 possible cases of HIV that were reported among healthcare professionals. Of these only 57 of the exposed workers seroconverted to HIV. Percutaneous needlestick injury was the known cause in 84% of these cases. Other infections acquired from exposure were 9% by the mucocutaneous route and 4% by both routes.

In the United States, the majority of people who have developed HIV as a result of needlestick injuries have been nurses, laboratory workers, non-surgical physicians, and nonclinical laboratory physicians.

Several prospective studies have on healthcare workers who have suffered occupational HIV exposure have been done. The data reveal that the risk of transmission from a single percutaneous needle stick or cut with a scalpel from an HIV infected individual is about 0.3% or 3 out of every 1000 healthcare workers. However, there are several other studies that indicate that the risk of HIV actuating after a needlestick injury is a lot higher, especially in individuals who have been exposed to a higher quantity of blood and struck with a large bore needle. Others who are at a higher risk is when they are exposed to patients with high viral titers or from those patients who have just seroconverted at the time of the needlestick injury ¹³.

Evaluation

Usually, the only evaluation is a thorough history and physical exam. Rarely, there may be a concern of a foreign body in which case an x-ray, ultrasound, or CT should be considered ¹⁴.

Laboratory studies include HIV and a hepatitis panel.

Evaluating for HIV: CDC 3-Step Risk Assessment

The prerequisite for starting Post-Exposure Prophylaxis (PEP) for HIV with antiretrovirals is based on evaluating the risk by using the 3-step process developed by the CDC (2014b) and other agencies ¹⁵:

Step 1 Determine the Exposure Code

One determines the exposure source which may be blood, bodily fluid or an instrument contaminated with blood (e.g., scalpel). If none, then the risk of HIV transmission is nil. If the answer is yes, then one has to determine the type of exposure:

• If exposure occurred to intact skin, then the risk of acquiring HIV is nil
• If exposure occurred to mucous membrane or in an area of the body where the skin was not intact (e.g., ulcer), one should determine the volume of fluid exposure – few or large drops and the duration of contact.
• If the exposure was via percutaneous, then was it via a superficial abrasion or a solid needle?
• What type of needle was involved? Large bore hollow needle and was it used to obtain blood from the patient’s vein or artery?

Step 2 Status of Patient

It is important to know the HIV status of the patient. If negative, then Post-Exposure Prophylaxis (PEP) is not required. If the patient was HIV positive, what was the viral titer (low or high?) and CD4 count. If the HIV status of the patient is unknown, clinical judgment and patient’s past medical history is necessary to determine the status.

Step 3 Decision on Treatment

Once the above data are collected post-exposure prophylaxis is determined. In general, if the risk of HIV exposure is low, then there is no need for treatment, but the observation is recommended. Individuals at high risk for HIV exposure are offered post-exposure prophylaxis. There are always some cases where the risk may be indeterminate because the patient may not be available for testing. In such cases, one should weigh the benefits of HAART versus the potential adverse effects.

• The CDC has a Post-Exposure Prophylaxis (PEP) hotline and website available that can help with management decisions (https://www.cdc.gov/hiv/guidelines/preventing.html).
• Visit the Non-Occupational Post-Exposure Prophylaxis (nPEP) Toolkit from the AETC National Coordinating Resource Center (https://aidsetc.org/npep).

Post exposure prophylaxis for HIV

Post-Exposure Prophylaxis (PEP) is a short course of HIV medicines (antiretroviral drugs) taken very soon for people who are HIV-negative after a possible high-risk exposure to HIV to prevent the virus from taking hold in your body. Such an exposure typically occurs through sex or sharing syringes (or other injection equipment) with someone who has or might have HIV. Exposure to HIV is a medical emergency, because HIV establishes infection very quickly, often within 24 to 36 hours after exposure. You must start Post-Exposure Prophylaxis (PEP) within 72 hours after you a possible exposure to HIV or it won’t work ¹⁶ and continued for 4 weeks. Every hour counts.

Post-Exposure Prophylaxis (PEP) should be used only in emergency situations. It is not meant for regular use by people who may be exposed to HIV frequently.

Today the recommendations for post-exposure prophylaxis involve the use of 3-antivirals. The drug treatment should be initiated as soon as possible, preferably within hours of exposure. The duration of treatment is for 4 weeks.

Currently, the CDC recommends using two nucleoside reverse transcriptase inhibitors (NRTIs) combined with a third drug, which is usually a protease inhibitor. For example, one may combine Tenofovir, emtricitabine plus either dolutegravir or raltegravir. Zidovudine is no longer utilized in this drug regimen because it has not been shown to offer any additional advantage. See CDC’s guidelines for additional alternate basic regimens and alternate expanded regimens (https://www.cdc.gov/hiv/pdf/programresources/cdc-hiv-npep-guidelines.pdf).

The recommended Post-Exposure Prophylaxis (PEP) regimen

• All persons offered Post-Exposure Prophylaxis (PEP) should be prescribed a 28-day course of a 3-drug antiretroviral regimen. Since adherence is critical for Post-Exposure Prophylaxis (PEP) efficacy, it is preferable to select regimens that minimize side effects, number of doses per day and the number of pills per dose. The preferred Post-Exposure Prophylaxis (PEP) regimen for otherwise healthy adults and adolescents is tenofovir disoproxil fumarate (TDF) (300 mg) + emtricitibine (FTC) 200 mg) once daily PLUS raltegravir (RAL) (400 mg) twice daily or dolutegravir (DTG) (50 mg) once daily) ¹⁷.

Once a needlestick injury has occurred, the healthcare worker must seek emergency care. The site of the needlestick must be thoroughly rinsed with saline or water, and the wound must be cleaned. In most cases, there is no need to use antiseptic solutions to wash the area. Wound infections usually do not develop within the first 24 hours. Following the injury, there is acute pain, and then most individuals have no other immediate symptoms. However, anxiety, panic, and apprehension are very common because of the fear of contracting a viral infection.

It is important to follow all state, institution and federal guidelines for reporting all needlestick exposures. There is also a federal law which ensures that all employers of such injuries receive complete medical coverage, including post-exposure prophylaxis and vaccine within a reasonable time at no cost to the employee ¹⁸.

How do I know if I need Post-Exposure Prophylaxis (PEP)?

If you are HIV-negative and you think you may have been recently exposed to HIV, contact your health care provider immediately or go to an emergency room right away.

You may be prescribed Post-Exposure Prophylaxis (PEP) if you are HIV-negative or don’t know your HIV status, and in the last 72 hours you:

• Think you may have been exposed to HIV during sex (for example, you had a condom break)
• Shared needles or works to prepare drugs
• Were sexually assaulted

Your health care provider or emergency room doctor will evaluate you and help you decide whether Post-Exposure Prophylaxis (PEP) is right for you.

In addition, if you are a health care worker, you may be prescribed Post-Exposure Prophylaxis (PEP) after a possible exposure to HIV at work, such as from a needlestick injury.

Who is not eligible for Post-Exposure Prophylaxis (PEP)?

• Post-Exposure Prophylaxis (PEP) is only indicated for potentially exposed people without HIV infection.
• Post-Exposure Prophylaxis (PEP) is unlikely to be effective in people who have been exposed more than 72 hours before seeking medical assistance.
• Post-Exposure Prophylaxis (PEP) should be provided only for infrequent exposures. People who engage in behaviors that result in frequent, recurrent exposures to HIV should be considered for intensive sexual or injection risk-reduction interventions and pre-exposure prophylaxis (PrEP) with daily oral doses of combination tenofovir disoproxil fumarate (TDF) + emtricitibine (FTC) (Truvada®). However if the most recent recurring exposure is within the 72-hour window prior to an evaluation, Post-Exposure Prophylaxis (PEP) may be indicated with transition of the patient to pre-exposure prophylaxis (PrEP) after completion of 28 days of Post-Exposure Prophylaxis (PEP) medication.

Which types of exposure warrant Post-Exposure Prophylaxis (PEP)?

Post-Exposure Prophylaxis (PEP) initiation should be considered in people whose vagina, rectum, eye, mouth or other mucuous membrane, non-intact skin, or perforated skin (eg, needle stick) come into contact with potentially contaminated body fluids from an HIV-infected source, as long as exposure has occurred within a 72-hour window. If the source is of unknown HIV status, a case-by-case determination may be made.

What baseline assessment is required for individuals beginning Post-Exposure Prophylaxis (PEP)?

Guidelines recommend the following baseline screening before initiating Post-Exposure Prophylaxis (PEP):

• HIV rapid test at baseline. If baseline rapid test indicates existing HIV infection, Post-Exposure Prophylaxis (PEP) should not be started. However, if rapid HIV baseline test is not available, there should be no delay in starting Post-Exposure Prophylaxis (PEP). Oral HIV tests are not recommended for use among persons being evaluated for Post-Exposure Prophylaxis (PEP).
• Pregnancy test (if a woman is of reproductive age, not using highly effective contraception, e.g., IUDs or other long-active reversible contraceptives (LARCs), oral contraceptives, or properly used condoms, and with vaginal exposure to semen). On 5/5/18, the U.S. Food and Drug Administration (FDA) alerted the public that serious cases of neural tube birth defects have been reported in babies born to women with HIV who were treated with the drug dolutegravir prior to conception. The CDC has issued an interim statement on the implications for PEP. Talk to your health care professional.
• Serum liver enzymes
• Blood urea nitrogen (BUN) and creatinine
• Sexually transmitted infection screening: Persons being evaluated for Post-Exposure Prophylaxis (PEP) because of a sexual encounter should have sexually transmitted infection-specific nucleic acid amplification (NAAT testing) for chlamydia and gonorrhea, and a blood test for syphilis
• Hepatitis B testing, including hepatitis B surface antigen, surface antibody, and core antibody
• Hepatitis C (HCV) antibody

Note: The first dose of Post-Exposure Prophylaxis (PEP) should always be expedited; testing can wait until after Post-Exposure Prophylaxis (PEP) has been initiated.

Who can prescribe Post-Exposure Prophylaxis (PEP)?

Any licensed prescriber can prescribe Post-Exposure Prophylaxis (PEP). Emergency medicine physicians are among the most frequent prescribers of Post-Exposure Prophylaxis (PEP), given the need for immediate treatment after exposure. Clinicians working in ambulatory care practices can also ensure that their non-HIV-infected patients who report risk behavior are aware of Post-Exposure Prophylaxis (PEP), and know how to access it.

Is Post-Exposure Prophylaxis (PEP) safe?

The current preferred regimen is generally safe and well tolerated. Patients usually experience only mild side effects on the preferred Post-Exposure Prophylaxis (PEP) regimen. Most importantly, Post-Exposure Prophylaxis (PEP) is only taken for 28 days. In almost all cases, the benefits of HIV prevention outweigh any other risks posed by the medication. In a meta-analysis of 24 Post-Exposure Prophylaxis (PEP)-related studies, including 23 cohort studies and 1 randomized clinical trial, nausea, vomiting, diarrhea and fatigue were the most commonly reported side effects.

How long do I need to take Post-Exposure Prophylaxis (PEP)?

If you are prescribed Post-Exposure Prophylaxis (PEP), you will need to take the HIV medicines every day for 28 days.

You will also need to return to your health care provider at certain times while taking Post-Exposure Prophylaxis (PEP) and after you finish taking it for HIV testing and other tests.

How well does Post-Exposure Prophylaxis (PEP) Work?

Post-Exposure Prophylaxis (PEP) is effective in preventing HIV infection when it’s taken correctly, but it’s not 100% effective. The sooner you start Post-Exposure Prophylaxis (PEP) after a possible HIV exposure, the better.

While taking Post-Exposure Prophylaxis (PEP), it’s important to keep using other HIV prevention methods, such as using condoms the right way every time you have sex and using only new, sterile needles and works when injecting drugs.

Can I take Post-Exposure Prophylaxis (PEP) every time I have unprotected sex?

No. Post-Exposure Prophylaxis (PEP) should be used only in emergency situations. It is not intended to replace regular use of other HIV prevention methods. If you feel that you might be exposed to HIV frequently, talk to your health care professional about pre-exposure prophylaxis (PrEP).

What additional support is required for patients on Post-Exposure Prophylaxis (PEP)?

Providers should maintain contact with their patients on Post-Exposure Prophylaxis (PEP), either by telephone or in a clinic visit for the entire duration of Post-Exposure Prophylaxis (PEP). This is both to ensure adherence and to facilitate follow-up HIV testing at 30 and 90 days to determine if HIV infection has occurred. Additionally, people whose sexual or injection-related exposures result in concurrent acquisition of HCV and HIV infection might have delayed HIV seroconversion.

Will Post-Exposure Prophylaxis (PEP) be covered by my patients’ health insurance?

In many states, Post-Exposure Prophylaxis (PEP) is covered by insurance, including Medicaid. If the patient is not covered under insurance, there are assistance programs run by various manufacturers.

Prophylactic treatment for rabies

Rabies is a fatal but preventable viral disease. Rabies can spread to people and pets if they are bitten or scratched by a rabid animal. In the United States, rabies is mostly found in wild animals like bats, raccoons, skunks, and foxes ¹⁹. However, in many other countries dogs still carry rabies, and most rabies deaths in people around the world are caused by dog bites.

The rabies virus infects the central nervous system. If a person does not receive theappropriate medical care after a potential rabies exposure, the virus can cause disease in the brain, ultimately resulting in death. Rabies can be prevented by vaccinating pets, staying away from wildlife, and seeking medical care after potential exposures before symptoms start.

If you’ve been in contact with any wildlife or unfamiliar animals, particularly if you’ve been bitten or scratched, you should talk with a healthcare or public health professional to determine your risk for rabies or other illnesses. Wash any wounds immediately with soap and water and then plan to see a healthcare provider. (It’s important to know that, unlike most other animals that carry rabies, many types of bats have very small teeth which may leave marks that disappear quickly. If you are unsure, seek medical advice to be safe.)

Remember that rabies is a medical urgency but not an emergency. Decisions should not be delayed.

See your doctor for attention for any trauma due to an animal attack before considering the need for rabies vaccination. After any wounds have been addressed, your doctor – possibly in consultation with your state or local health department – will help you decide if you need treatment known as rabies postexposure prophylaxis (PEP). Decisions to start Post-Exposure Prophylaxis (PEP) will be based on your type of exposure, the animal you were exposed to, whether the animal is available for testing, and laboratory and surveillance information for the geographic area where the exposure occurred.

In the United States, Post-Exposure Prophylaxis (PEP) consists of a regimen of one dose of immune globulin and four doses of rabies vaccine over a 14-day period. Rabies immune globulin and the first dose of rabies vaccine should be given by your health care provider as soon as possible after exposure. Current vaccines are relatively painless and are given in your arm like a flu or tetanus vaccine; rabies vaccines are not given in the stomach.

Rabies post-exposure prophylaxis

Post-exposure prophylaxis (PEP) consists of a dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3, 7, and 14 ²⁰. For people who have never been vaccinated against rabies previously, postexposure prophylaxis (PEP) should always include administration of both human rabies immune globulin and rabies vaccine. The combination of human rabies immune globulin and rabies vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment.

People who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only rabies vaccine.

Adverse reactions to rabies vaccine and immune globulin are not common. Newer vaccines in use today cause fewer adverse reactions than previously available vaccines. Mild, local reactions to the rabies vaccine, such as pain, redness, swelling, or itching at the injection site, have been reported. Rarely, symptoms such as headache, nausea, abdominal pain, muscle aches, and dizziness have been reported. Local pain and low-grade fever may follow injection of rabies immune globulin.

The vaccine should be given at recommended intervals for best results. Talk to your doctor or state or local public health officials if you will not be able to have your shots at the recommended interval. Rabies prevention is a serious matter and changes should not be made in the schedule of doses. Patient assistance programs that provide medications to uninsured or underinsured patients are available for rabies vaccine and immune globulin.

People cannot transmit rabies to other people unless they themselves are sick with rabies. Post-exposure prophylaxis (PEP) will protect you from developing rabies, and therefore you cannot expose other people to rabies. You can continue to participate in your normal activities.

References

1. King KC, Strony R. Needlestick. [Updated 2019 Dec 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493147
2. Triassi M, Pennino F. Infectious risk for healthcare workers: evaluation and prevention. Ann Ig. 2018 Jul-Aug;30(4 Supple 1):48-51.
3. Dulon M, Wendeler D, Nienhaus A. Seroconversion after needlestick injuries – analyses of statutory accident insurance claims in Germany. GMS Hyg Infect Control. 2018;13:Doc05.
4. Serna-Ojeda JC, Navas A, Graue-Hernandez EO. Smaller needles, lower risks?: Occupational HIV risk for healthcare professionals. HIV Med. 2017 Sep;18(8):613-614.
5. Hepatitis Exposure Management. http://nccc.ucsf.edu/clinical-resources/pep-resources/hepatitis-exposure-management/
6. Egro FM, Nwaiwu CA, Smith S, Harper JD, Spiess AM. Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: the University of Pittsburgh 13-year experience. Am J Infect Control. 2017;45(9):1001-5.
7. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
8. Demsiss W, Seid A, Fiseha T. Hepatitis B and C: Seroprevalence, knowledge, practice and associated factors among medicine and health science students in Northeast Ethiopia. PLoS ONE. 2018;13(5):e0196539
9. Naggie S, Holland DP, Sulkowski MS, et al. Hepatitis C virus postexposure prophylaxis in the healthcare worker: why direct-acting antivirals don’t change a thing. Clin Infect Dis. 2017 Jan 1;64(1):92-99. Epub 2016 Sep 28.
10. Mosley JW, Operskalski EA, Tobler LH, et al. The course of hepatitis C viraemia in transfusion recipients prior to availability of antiviral therapy. J Viral Hepat. 2008 Feb;15(2):120-8.
11. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm
12. Muller WJ, Chadwick EG. Pediatric Considerations for Postexposure Human Immunodeficiency Virus Prophylaxis. Infect. Dis. Clin. North Am. 2018 Mar;32(1):91-101.
13. Pereira MC, Mello FW, Ribeiro DM, Porporatti AL, da Costa S, Flores-Mir C, Gianoni Capenakas S, Dutra KL. Prevalence of reported percutaneous injuries on dentists: A meta-analysis. J Dent. 2018 Sep;76:9-18.
14. Rawal S, Bogoch II. Evaluation of non-sexual, non-needlestick, non-occupational HIV post-exposure prophylaxis cases. AIDS. 2017 Jun 19;31(10):1500-1502.
15. Arora G, Hoffman RM. Development of an HIV Postexposure Prophylaxis (PEP) Protocol for Trainees Engaging in Academic Global Health Experiences. Acad Med. 2017 Nov;92(11):1574-1577.
16. Post-Exposure Prophylaxis. https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/post-exposure-prophylaxis
17. PEP FAQs. https://www.cdc.gov/hiv/clinicians/prevention/pep.html
18. Stephenson J. Nurses should insist trusts obey sharp safety law. 2016 Feb 24-Mar 1Nurs Times. 112(8):2-3.
19. Rabies. https://www.cdc.gov/rabies/
20. Rabies Postexposure Prophylaxis (PEP). https://www.cdc.gov/rabies/medical_care/index.html