nPEP Reduces the Risk of HIV Infection

Katarzyna LaLicata, MSN, FNP-C, FNP-BC
Thursday June 27, 2019
An estimated 1.1 million people age 13 and older had HIV infection at the end of 2016, with an estimated 14% of those whose infections had not been diagnosed, according to the CDC.
 
As of 2017, the states reporting the highest number of HIV diagnoses are Florida, California, Texas, New York, Georgia, North Carolina, Illinois, New Jersey, Pennsylvania, and Louisiana.1 The CDC provides guidelines for the use of antiretroviral post-exposure prophylaxis after sexual contact, injection drug use, and other non-occupational post-exposure prophylaxis (nPEP). 
 
Providers can play an integral role to determine the appropriateness of nPEP, medication regime, and educating the patents about the importance of seeking help ideally immediately or within 72 hours of exposure and emphasize the importance of follow-up and medication compliance to help decrease the risk of HIV transmission. 
 
Myths exist regarding initiating nPEP, including adverse effects and reactions, the time to start, toxicity, and use in urban versus rural communities.2
 
Medications that are used for nPEP have less serious adverse effects, and their benefits  outweigh the risks. To be most effective, these medications  should ideally be started as soon as possible to exposure, ideally within 1 to 2 hours but no later than 72 hours and taken daily for 28 days. The location should not be used to evaluate the need for nPEP. Rather, the acquisition risk should be used for nPEP.3
 
Providers should evaluate patients immediately, and HIV testing should be done prior to initiating nPEP. If rapid testing is not possible, then send blood to a lab for evaluation, with nPEP initiated immediately. Patients given nPEP need to be prescribed a 28-day course of a 3-drug antiretroviral regimen and given the first dose on site immediately after exposure. It is important to stress adherence to the 28-day dose regime without interruption to the patient as an integral part of the treatment. It is essential to educating patients that though severe adverse effects are rare, they still may occur.3
 
The AETC National Clinical Consultation Center’s Post-Exposure Prophylaxis Hotline (888-HIV-4911 or 888-448-4911, 9 a.m. to 9 p.m., 7 days a week), works with providers to assess the risk of exposure, determine the appropriateness of prescribing PEP, select the best PEP regimen, and provide recommendations for follow-up testing.3
 
Initiating nPEP is recommended when the source of body fluids is known to be HIV-positive and the reported exposure presents a substantial risk of transmission, including via breast milk, eye, mouth, mucus membranes, non-intact skin, percutaneous exposure to blood, rectal secretions, rectum, semen, vagina, vaginal secretions , or any bodily fluid that is visibly contaminated with blood when the source known to be HIV-positive.4,5

Initiating nPEP is not recommended when the reported exposure presents no substantial risk of HIV transmission or when care is sought > 72 hours after potential exposure. 

If the HIV status of the source is unknown and the reported HIV exposure presents a substantial risk for transmission, the provider should complete an initial nPEP evaluation  to determine if indicated on a case-by-case basis.4,5

Individuals should be prescribed a 28-day course of a 3-drug antiretroviral  regimen. For otherwise healthy adolescents and adults, the preferred regimen is tenofovir disoproxil fumarate (300mg) with emtricitabine (200 mg) once daily, plus raltegravir 400 mg twice daily or dolutegravir 50 mg daily. An alternative regimen is tenofovir DF (300 mg) with emtricitabine (200 mg) once daily, plus darunavir (800mg) and ritanovir (100mg) once daily. Zidovudine (AZT) is no longer recommended.4,6

For antiretroviral regimens for nPEP other than those listed by the CDC for patients, including children, pregnant women, or patients with comorbid conditions, such as impaired renal function, health care providers should consult experts in antiretroviral therapy.5,7 When evaluating those for possible nPEP, health care workers should provide prevention, treatment, or supportive care for other exposure-associated conditions and health risks, as indicated.

The Clinical Consultation Center recommends against using dolutegravir as post-exposure prophylaxis for exposed women, who are pregnant at less than 8 weeks of gestation, those who desire pregnancy, or are not using an effective method of contraception, because of a study that reported an increased risk of neural tube defects.6,8

The most effective methods for preventing HIV infection are those that protect against exposure, including abstinence, consistent and correct use of barrier devices, not using injection drugs, sex only in a mutually monogamous relationship with an uninfected HIV partner, and use of sterile equipment for those who are unable to cease injection drug use. Initiation of antiretroviral medication after isolated sexual, injection drug use, or other non-occupational HIV exposure, is less effective at preventing HIV infection than avoiding exposure to the virus.4

Conclusion
For those who report behaviors or situations that place them at risk for frequently recurring HIV exposures (eg, injection drug use or sex without condoms) or who report receipt of ≥ 1 course of nPEP in the past year, the provider should consider intervention services, pre-exposure prophylaxis, and risk reduction counseling.4 Clinicians must evaluate the need for nPEP immediately and collaborate with other health care providers who have expertise in antiretroviral medications and pharmacists to ensure proper management.  


Katarzyna LaLicata, MSN, FNP-C, FNP-BC, is a nurse practitioner at CVS MinuteClinic and an associate clinical assistant professor at National University in San Diego, California.


References
  1. CDC. HIV surveillance report. cdc.gov/hiv/statistics/overview/index.html. Published April 12, 2019. Accessed April 21, 2019
  2. nPEP prescribing myths. aidsetc.org/sites/default/files/resources_files/nPEP-MYTHS-Flyer no trim.pdf. AIDS Education & Training Center website. Accessed April  21, 2019
  3. Prescribing nPEP. AIDS Education & Training Center website.  aidsetc.org/sites/default/files/resources_files/npep-toolkit-infographic-presentation.pdf. Accessed April 21, 2019
  4. CDC. Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV— United States, 2016. . cdc.gov/hiv/pdf/programresources/cdc-hib-npep-guidelines.pdf. Accessed April 21, 2019 
  5. HIV post-exposure prophylaxis, non occupational. Epocrates website. online.epocrates.com/noFrame/monographPrint?activeTab=2&activeDrugId=Accessed April 21, 2019.
  6. PEP for mon-occupational exposure to HIV (nPEP). New York State Department of Health AIDS Institute. hivguidelines.org/pep-for-hib-prevention/non-occupational/. Published May 2018. Accessed April 21, 2019.
  7. Okulicz JF. HIV postexposure prophylaxis (PEP), occupational: nonoccupational. Medscape. January 15, 2019. (nPEP). emedicine.medscape.com/article/2172304-overview. Accessed April 21, 2019.
  8. CCC update to FDA notice: dolutegravir and post-exposure prophylaxis (PEP). Clinician Consultation Center website. nccc.ucsf.edu/2018/06/01/ccc-update-to-fda-notice-dolutegravir-and-post-exposure-prophylaxis-pep/. Published June 1, 2018. Accessed April 21, 2019.
 
 
 
 
 



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