the US public health service just published new guidelines for healthcare workers with potential HIV exposures ( see hiv occup exposure guidelines 2013 DOI: 10.1086/672271, or http://www.jstor.org/stable/10.1086/672271 ). these are a pretty profound deviation from the previous guidelines, as follows (and, of course, these guidelines reinforce the importance of minimizing exposures as the primary approach):
–these guidelines are mostly based on the fact that there are newer and earlier tests for HIV (with the new 4th generation assays, which include the p24 antigen and antibodies to both HIV-1 and HIV-2), and that there are easier-to-take and more tolerable prophyllactic (ie, treatment, since there are no new significant data on prophyllaxis) regimens.
–so, even though HIV transmission is low (0.3% for percutaneous, 0.09% mucous membrane exposure), the working group suggests post-exposure prophyllaxis whenever there is an occup exposure (blood or other possibly infectious fluids), with 3 drugs started ASAP after exposure and given for 4 weeks. preferred regimen of truvada (tenofivir and emtricitabine) plus raltegravir. should try to get HIV (and, i would add, hep b and c) status of the source patient. if known, should modify this regimen depending on the HIV resistance pattern if the source patient has HIV. the exposed worker should have close followup, with initial followup appointment within 72 hours. so, these guidelines are remarkably easier than the 2005 ones, which required subjective assessment of the quality of the exposure as the guide to prophyllaxis with either 2 or 3 drugs.
–one issue is that ralteg is bid. there is a new once-a-day integrase inhibitor (dolutegravir) which is once daily and seems very very very promising (see hiv dolutegravir vs raltergravir lancet 2013 http://dx.doi.org/10.1016/S0140-6736(12)61853-4, for example), but i don’t think it is available yet. there are a slew of other potential regimens besides truvada/ralteg, if you are concerned about other toxicities, including (for example), either darunavir/riton, rilpivirine, atazanavir/ritonivir, lopinavir/riton, along with tenof/emtric (truvada) or AZT/3TC. all listed in their table A1, with dosing/toxicities in their table B1.
–remember to check on drug-drug interactions with meds the worker is taking. there is a section in the guidelines addressing if the worker is pregnant/breast-feeding
–since the new assay is more sensitive and picks up infection sooner, can decrease the followup testing to 4 months (vs 6 months)
needless to say/write, these guidelines do not incorporate other potentially transmissible bugs (eg hep b and c).
for specific clinical help if needed, you can contact the following (in the US)(i have used the HIV warmline many times to get input on clinical management of cases, and it is really great):
HIV warmline (general HIV cases) — 800-933-3413
HIV PEPline (postexposure prophyllaxis) — 888-448-4911
HIV Perinatal HIV hotline — 888-448-8765
geoff