TRIPASS XR تري باس

 

Emtricitabine/tenofovir disoproxil fumarate one tablet daily can be considered for

F.C. for the prevention of HIV. He will need to have baseline HIV, STI, and renal

function testing as well as medication adherence and behavioral risk reduction

counseling. He will need to follow up 3 months after emtricitabine/tenofovir

disoproxil fumarate if prescribed for monitoring and repeat HIV testing.

Postexposure Prophylaxis

CASE 76-6

QUESTION 1: L.T. is a 47-year-old nurse at an HIV clinic. While drawing routine labs on a newly diagnosed

HIV+ male patient, not yet started on HAART, she accidently stuck herself with a contaminated needle. Are

interventions available to prevent L.T. from contracting HIV from the needlestick? What drugs should be

utilized, and for how long?

Postexposure prophylaxis (PEP) is the use of ARVs to prevent HIV infection in

individuals who have had an exposure to blood or body fluid either known to be

infected with HIV or potentially infected with HIV. Occupational exposures require

immediate evaluation with a first dose of ARVs offered within the first 2 hours

following exposure.

129

,

130 PEP is more effective the earlier it can be initiated, and it

should always be started within 72 hours of exposure. Percutaneous exposure poses

more of a concern than mucous membrane exposure. A needle stick with a large

hollow-bore needle is higher risk than a solid needle, a deep penetrating wound is

considered a high-risk exposure compared to a superficial injury, and a exposure to a

large volume of infectious fluid is more concerning than exposure to a low volume.

Patient-specific factors must also be considered, such as whether the HIV-positive

patient is on HAART therapy and has a suppressed viral load or whether the HIVpositive patient currently has a high viral load. Regardless of the type of exposure or

risk factors, current guidelines recommend that PEP be offered to all health care

workers with an exposure. If the source patient is known to be HIV positive or the

HIV status is not known, PEP should be continued for a total of 4 weeks, or 28 days.

If the source patient’s status is unknown but is later determined to be HIV negative,

then PEP can be discontinued prior to 28 days.

129

,

130

Three-drug PEP is recommended for all health care workers exposed or possibly

exposed to HIV. Recommended regimens include two NRTIs with either raltegravir

or dolutegravir. Alternative regimens include two NRTIs with a boosted PI.

130

In instances where the source patient is a known treatment experienced patient

with HIV, the choice of agents to use for PEP is generally dependent on the patient’s

regimen and resistant profile.

129

,

130

L.T. should start immediately a PEP regimen, preferably emtricitabine/tenofovir

disoproxil fumarate once daily with raltegravir twice daily or dolutegravir once

daily. This entire regimen should be continued for a total of 4 weeks. It would also

be a good idea to look at the specific patient from which the exposure occurred. If he

had a great deal of known antiretroviral drug resistance, then L.T. may need to be put

on different antiretrovirals according to the patient’s resistance profile. HIV antibody

testing using ELISA should be performed on L.T. at baseline exposure, 6 weeks, 12

weeks, and 6 months after exposure. She should also have baseline and follow-up

labs performed to assess antiretroviral toxicity. At a minimum, these should include a

complete blood count, renal and hepatic function tests, and fasting glucose while on

the protease inhibitor. Additional laboratory tests should be performed based on the

individual drugs chosen.

129

,

130

Additional guidelines exist for non-occupational HIV exposures and follow

similar risk and stratification treatment paradigms. In those instances where a person

seeks care within 72 hours of exposure to blood, genital secretions or other

potentially infected body fluids of persons known to be HIV-infected and the

exposure represents a substantial risk for HIV transmission then the person is started

on PEP in a similar fashion as with an occupation exposure and continued for 4

weeks with similar monitoring and HIV testing.

131

KEEPING CURRENT

The management of HIV infection continues to evolve. Additional important emerging

data are in HIV prevention and cure.

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p. 1594

Table 76-7

Human Immunodeficiency Virus Internet Resources

Government Sites

American Foundation for AIDS Research: http://www.amfar.org

Centers for Disease Control and Prevention: http://www.cdc.gov

Consensus Panel Guidelines Online: http://www.aidsinfo.nih.gov

Government HIV Mutation Charts: http://hiv-web.lanl.gov

National Institute of Allergy and Infectious Diseases: http://www.niaid.nih.gov

National Prevention Information Network: https://npin.cdc.gov/

United Nations AIDS Website: http://www.unaids.org/

University Sites

University of Stanford HIV Drug Resistance Database: http://hivdb.stanford.edu/

AIDS Treatment/Advocacy Groups

Project Inform: http://www.projectinform.org/

San Francisco AIDS Foundation: http://www.sfaf.org/index.html

Other Relevant Sites

The AIDS Map: http://www.aidsmap.com

Clinical Care Options: http://www.clinicalcareoptions.com

HIV Drug Interactions: http://www.hiv-druginteractions.org

HIV and Hepatitis: http://hivandhepatitis.com

HIV Treatment Information: http://i-base.info/

Medscape: http://www.medscape.com

Physician’s Research Network: http://www.prn.org

The Body for Clinicians: http://www.thebodypro.com

The overwhelming data presented at scientific meetings and in journals have made

staying informed about current issues and new developments a daunting task. As a

result, many clinicians, even those actively caring for patients who are HIV infected,

remain cautious and often confused regarding therapeutic options.

New technologies for the dissemination of medical information are constantly

evolving. The Internet has allowed clinicians worldwide to exchange ideas, teach

new concepts, and obtain access to limited resources. In addition, many research

centers, patient advocacy groups, and academic institutions have posted sites on the

Internet that have resulted in access to large amounts of high-quality medical

information. This new technology has also allowed, however, for the dissemination

of incomplete, misleading, or inaccurate information. Therefore, clinicians must

remain cautious and carefully evaluate the information obtained from various

websites.

When evaluating the quality of a website, clinicians should look for a few basic

standards.

Author qualifications. Is the author qualified to write the article or perform the

research? Is his or her affiliation or relevant credentials provided?

Attribution. Are references provided to confirm statements? Is all relevant

copyrighted information noted?

Currency. When was the content posted? Is the website updated regularly?

Disclosure. Who owns the website? Is there a conflict of interest between what is

being posted and any commercial interest?

Any Internet site that fails to meet these basic competencies should be viewed with

caution. In general, the most accurate and informative websites for HIV-specific

information come from academic institutions, government organizations, medical

societies, and patient advocacy groups. Table 76-7 lists high-quality websites that

provide timely and accurate information. A periodic evaluation of these sites often

provides sufficient information to stay up-to-date on current issues and controversies.

CONCLUSION

Given the significant advances in antiretroviral therapy over the past 30 years, HIV-1

infection is now a manageable chronic disease for those who have access to

antiretroviral therapies. The pharmacologic management of HIV continues to rapidly

evolve, but a basic understanding of viral pathogenesis and drug interactions

provides a framework that can be used to evaluate new information as it becomes

available. Although a cure is still out of reach, methods for preventing infection via

treatment as prevention, PrEP, PEP, and through the prevention of perinatal

transmission, have become increasingly effective as alternative strategies for curbing

the epidemic.

KEY REFERENCES AND WEBSITES

A full list of references for this chapter can be found at

http://thepoint.lww.com/AT11e. Below are the key references and websites for this

chapter, with the corresponding reference number in this chapter found in parentheses

after the reference.

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p. 1595

Key References

Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. N EnglJ Med. 2011;365:493. (12)

Gunthard HF et al. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults 2016

Recommendations of the International Antiviral Society–USA Panel. JAMA. 2016;316(2):191-210. (5)

INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J

Med. 2015;373:795–807. (65)

Temprano ANRS 12136 Study Group. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N

EnglJ Med. 2015;373:808–822. (66)

Wensing AM et al. 2017 Update of the drug resistance mutations in HIV-1. Top Antivir Med. 2017;24(4):132-141.

(4)

Key Websites

Centers for Disease Control and Prevention. HIV in the United States. 2015;

https://www.cdc.gov/hiv/basics/index.html. Accessed June 15, 2015. (9)

Centers for Disease Control and Prevention.

Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission.

Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and

Interventions to Reduce Perinatal HIV Transmission in the United States.

https://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/#. Accessed August 7, 2017. (121)

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in

HIV-1-infected adults and adolescents. Department of Health and Human Services.

https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/0/. Accessed

August 7, 2017. (3)

US Public Health Service. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States—

2014 Clinical Practice Guideline. U.S. Department of Health and Human Services and Center for Disease

Control. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf. Accessed May 31, 2015. (128)

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