The provision of nonoccupational post-exposure prophylaxis (NPEP) to people who have been exposed to a possible risk of HIV infection is explored in the 15th January 2003 edition of the Journal of the American Medical Association.
The article is prompted by the decision of the US state of Rhode Island to provide guidance to healthcare professionals on the provision of NPEP. The guidelines were issued after the Rhode Island Health Department became concerned that “prophylaxis for nonoccupational exposure was being handled inappropriately by clinicians.” In some cases prophylaxis was being provided when it wasn’t needed and in others the wrong, or inappropriate medication was being provided.
Clinicians in Rhode island are recommended to first assess the risk of HIV exposure. According to their guidance, NPEP should be offered following possible exposure with a person known to be HIV-positive. It may also be offered after high risk exposures (such as unprotected sex with a person who has had multiple sexual partners or is an injecting drug user), and may be considered if a person has had a low risk exposure (such as an unprotected sexual contact with a person of no recognised risk behaviours for HIV).
When offered, treatment should be provided within a maximum of 72 hours and preferably within one hour of exposure, say the guidelines.
Also included in the guidelines are recommendations for drug regimens to be used. Following exposure with a person known to be HIV-positive, it is recommended that a triple combination, containing a protease inhibitor be provided for 28 days. Where possible, the clinician responsible for the care of the HIV-positive person should be contacted to obtain details of the contact’s HIV treatment history and known resistance profiles.
In all other instances a dual combination should be provided for four weeks. In all cases, people receiving NPEP should receive information about dosing, potential side-effects, and possible drug interactions. For healthcare professionals, the guidelines include details of which tests should be undertaken on people with possible HIV infection.
The guidelines stress that NPEP is not a substitute for HIV prevention programmes. Dr Ronald Merchant, one of the authors of the Rhode Island guidelines said: “Primary prevention is very important but we need to find other ways [to prevent HIV]” adding, “HIV NPEP is not the end-all, but it can be one part of our armamentarium for decreasing the incidence of HIV.” It remains to be seen if other HIV physicians agree.
Further information on this website
PEP - Treatment during primary infection
PEP - Links to PEP guidance and policy from around the world
Stephenson J. PEP talk: treating nonoccupational HIV exposure JAMA 289: 287-288, 2003.