The HIV status of the source should be classified as HIV-positive or unknown at the time of the initial evaluation. Thus, treatment decisions should be made based upon the nature of the exposure and when the exposure occurred. Once the need for nPEP has been identified, the patient should receive a dose as soon as possible (and within 72 hours of the exposure), even if HIV testing of the exposed patient and source have not yet been performed. After the initial dose has been administered, HIV testing and a more detailed history can be obtained. At that time, patients should also be assessed for hepatitis B and C virus, and sexually transmitted infections (depending upon the type of exposure).
ART: antiretroviral therapy; EVG/c/FTC/TDF: Elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate; FTC: emtricitabine; nPEP: nonoccupational post-exposure prophylaxis; TDF: tenofovir disoproxil fumarate. Antiretroviral abbreviations separated by "/" (eg, TAF/FTC) are available in single-tablet coformulations. * High-risk exposure includes: Having condomless receptive or insertive vaginal or anal intercourse with a source who is HIV-infected, or a source whose HIV status is unknown, but it is at high risk for HIV (eg, men who have sex with men, injection drug users, sex workers); having a percutaneous exposure to blood (or body fluids contaminated with blood) from a patient who is HIV-infected or with the risk factors described above; or having been sexually assaulted. ¶ Preferred regimens: The coformulated tablet TDF/FTC in combination with raltegravir or dolutegravir. Alternative regimens include: EVG/c/FTC/TDF, TDF/FTC plus a pharmacologically-boosted PI (eg, darunavir plus ritonavir or darunavir/cobicistat), or rilpivirine/emtricitabine/TDF. There is an increased risk of drug interactions if a pharmacologic boosting agent (cobicistat or ritonavir) is used. Δ For individuals with reduced kidney function, TDF and FTC cannot be administered as a coformulated tablet and the dosage must be adjusted according to the patient's renal function. In addition, TDF and cobicistat should only be administered together if the eGFR is >70 mL/min/1.73 m2. ◊ If the source patient is at risk for having drug-resistant virus (eg, those who have failed multiple regimens as well as those with known non-adherence), our preferred nPEP regimen is the coformulated tablet TDF/FTC in combination with dolutegravir. An alternative regimen is TDF/FTC plus a pharmacologically-boosted PI (eg, darunavir plus ritonavir or darunavir/cobicistat). Such patients are best managed in conjunction with an experienced HIV provider. § Refer to the topic that discusses the clinical manifestations of acute HIV infection. ¥ HIV-infected patients with a stably suppressed viral load are unlikely to transmit HIV. Decisions to continue nPEP should be made on a case-by-case basis. Refer to the topic that discusses HIV prevention.
Graphic 108662 Version 1.0
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