If the Condom Breaks: New U.S. Guidelines for Non-Occupational Exposure to HIV

by John S. James

Summary: Finally there are U.S.-government guidelines for prevention of non-occupational HIV exposure, for example after rape or accident.

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In case of significant accidental exposure to HIV it is important to begin a 28-day course of antiretrovirals immediately to reduce the risk that HIV infection could be established. New (January 20, 2005) U.S. guidelines for preventing HIV infection after exposure through sexual intercourse, sexual assault, injection drug use, or accidents are available at
http://www.aidsinfo.nih.gov/guidelines/ (click "Nonoccupational ..." on the left)
or
http://www.cdc.gov/mmwr/mmwr_rr.html

Most importantly, treatment must begin as soon as possible. After 72 hours is probably too late (although the guidelines note that physicians might consider treatment even after 72 hours "for exposures conferring a serious risk of transmission"). Treatment should begin much earlier than 72 hours if at all possible.

The new guidelines do not specify what drugs should be used, but refers to three-drug combinations recommended for treatment of persons already infected with HIV. The guidelines caution against nevirapine because of its potentially life-threatening side effects in HIV-negative people (when used continuously -- these side effects do not happen from a single dose). And efavirenz should be avoided in pregnant women and "women of childbearing potential" (presumably meaning women who might become pregnant while this drug is in the body).

These nPEP (non-occupational post-exposure prophylaxis) guidelines are similar but not the same as the guidelines for treating healthcare workers exposed by a needlestick or other accident on the job.

New California Guidelines Also

California also issued its own non-occupational post-exposure guidelines recently (both the U.S. and California guidelines had been greatly delayed). A January 27 email update from the American Association of HIV Medicine (AAHIVM) compared the documents as follows:

"The state of California also released its recommendations last week. With two summary tables, patients information sheets, sample scripts about how to address the key issues in PEP and even a sample progress note, they offer a user-friendly, slightly different perspective on some key issues. These issues include: how many medications to use, how many blood tests are needed, and how to think about who is at the greatest risk.

"The California guidelines are available at http://www.dhs.ca.gov/ps/ooa.

"Critically, both guidelines stress the need for risk reduction counseling and referrals to help people stay HIV negative not only as a result of the presenting exposure, but over the long-term. This is the real opportunity that PEP provides to the individual."

For More Information

For background and Web links on prevention of HIV infection after non-occupational exposure, see "Prophylaxis Following Nonoccupational Exposure to HIV" by Michelle Roland, M.D., published online in HIV InSite Knowledge Base,
http://hivinsite.ucsf.edu/InSite?page=kb-07-02-07.

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