new HIV recommendations for nonoccupational exposures to HIV

 The CDC just released their 2025 updated antiretroviral post-exposure prophylaxis after sexual, injection drug use, or other nonoccupational exposures to HIV: see hiv postexp prophylaxis 2025 in dropbox, or  https://www.cdc.gov/mmwr/volumes/74/rr/rr7401a1.htm#T4_down.  thanks to Karen Magsipoc for bringing this to my attention

Review:

--these recommendations refer to nonoccupational postexposure prophylaxis (nPEP) by sexual, needle, or other exposure to nonintact skin or mucous membranes that presents a substantial risk for HIV transmission, in the setting of a contact with HIV who lacks sustained viral suppression or their viral suppression is unknown

    -- these guidelines update the prior 2016 ones, and most significantly includes the new antiretrovirals

    -- if the source person has unknown HIV status, the nPEP determination should be based on the available information, though treatment should not be delayed for the purpose of investigating the source's HIV status

    -- if the source person is a male who has sex with men and is taking HIV pre-exposure prophylaxis (PrEP), the HIV risk reduction efficacy is 99% if taking at least 4 doses of tenofovir disoproxil fumarate(TDF) per week; vaginal tissue concentrations of TDF and emtricitabine require 6-7 doses/week. limited data are available on injectable PrEP and intermittent PrEP.

        -- Bottom line: it is prudent to consider any pattern of tenofovir use outside those recommended in the PrEP guidelines to be "nonadherent" and get nPEP

-- a rapid HIV test (eg point-of-care, or antigen/antibody combo HIV test) should be done prior to starting therapy.

-- first dose of meds should be taken as soon as possible, best within 24 hours, and no later than 72 hours after exposure (and do not delay to wait for results of the HIV testing)

--a 28-day course is recommended, unless appropriate testing finds that the source person is HIV negative, at which time the nPEP can be stopped

-- Laboratory testing:

    -- initial testing: point-of-care or laboratory-based antigen/antibody combination HIV test; people having long-acting injectable PrEP antiretroviral therapy exposure during the past 12 months should also have a diagnostic HIV nucleic acid test (NAT)

        -- other routine recommended lab testing: serum creatinine, ALT, AST, as well as HIV, hep B, and pregnancy testing

        -- test and treat; hepatitis C infection; other STI’s including gonorrhea, chlamydia, and syphilis; and other medical treatment should be tailored to the clinical situation

            -- check for transaminase levels, since they can be elevated when on or after discontinuing HIV meds, especially if patient has hepatitis B or C. also consider other comorbidities in choosing the HIV meds, such as low bone mineral density, cardiovascular disease, psychiatric illness, substance use disorder requiring narcotic replacement (eg see https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/tables-adult-adolescent-arv.pdf ), or for pregnant or breastfeeding women and women of childbearing potential (and check pregnancy test)

    -- follow-up testing: HIV testing with both laboratory-based HIV Ag/Ab test plus a diagnostic HIV NAT at 4 to 6 weeks after exposure (though this test could be deferred in people starting nPEP within 24 hours of a known or possible HIV exposure and do not miss any nPEP doses); final HIV testing using the HIV Ag/Ab combination and diagnostic HIV NAT 12 weeks after exposure

-- recommended follow-up: a visit (which can be remote) at 24 hours, and clinical follow-up in 4-6 weeks and 12 weeks after exposure for lab tests

-- nPEP can be stopped at any point if the source was found to have no substantial risk of transmissible HIV

-- pre-exposure prophylaxis (PrEP) should be offered if repeated HIV exposures are anticipated

-- and PrEP should be offered if the patient has ongoing indications for PrEP beyond the nonoccupational exposure

-- and, it is important to check drug-drug interactions when starting nPEP. one great source of info is the HIV Drug interaction checker from Liverpool: https://www.hiv-druginteractions.org/checker

-- appropriate counseling and education of patients to prevent further HIV exposure/potential infection

-- interviewing for domestic violence, sexual assault (in all ages, and certainly in kids)

-- here are the recommended meds, though recommendations should be individualized, eg if the source patient has resistant HIV, or some of the comorbidities noted above:

so, this is the best approach to nonoccupational exposures to HIV. it should be noted that most of the recommendations are not based on rigorous human data; many are based on animal studies, tissue levels of meds, "good practice statements" (ie expert opinion), and extrapolation of data from other HIV treatments

    -- of course, we cannot do randomized controlled trials on treatment regimens for nPEP with varying doses and therapies; we do need to take what appears to be the most appropriate and most conservative approach, as per the data/recommendations above

    -- and we do know from good studies that the recommended medications work extremely well in those who have HIV, and in fact these meds are much more aggressive than those used in PrEP to prevent sexual HIV transmission: https://gmodestmedblogs.blogspot.com/2019/06/uspstf-guidelines-on-hiv-testing-and.html

geoff

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