Hiv Medication Chart (Page 2 of 2) in pdf

Post-Exposure Management for Hepatitis C Virus (HCV)

CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR, 2001;50(RR-11), 1-53. Available at

CDC. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965. MMWR, 2012;61(4) 1-34. Available at

CDC. Testing for HCV Infection: An Update of Guidance for Clinicians and Laboratorians. MMWR, 2013;62(18), 357-365. Available at All accessed: December 8, 2014.

Management of Exposures to HCV

Post-Exposure Management for HCV

• Perform hepatitis C virus antibody test (HCV Ab) for the exposure source

; if source is an injection drug user or immunocompromised, consider adding HCV viral load testing

• No regimens proven beneficial for PEP

• Perform baseline testing for HCV Ab and alanine transaminase (ALT) activity for the exposed person

• Early identification of acute HCV and referral to hepatitis C

• Perform follow-up testing for the exposed person: HCV Ab and ALT at 4-6 months or HCV viral load at 4-6 weeks for earlier detection

specialist for management if infected

• Confirm HCV Ab results reported positive by testing for HCV viral load

5. CDC. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945-1965. MMWR, 2012;61(4) 1-34. Available at Accessed: December 8, 2014.

HIV Exposure Management

NOTE: Consider exposure to other blood-borne pathogens (e.g., hepatitis B and C) in addition to HIV. See sections on hepatitis B and C provided in this resource.

• PEP for non-occupational (nPEP) and occupational exposures (oPEP) should start IMMEDIATELY (ideally within 1-2 hours post exposure), and continue for 28 days, or until the source person is determined to be HIV-negative. Plasma HIV RNA testing of the source person is

recommended in addition to HIV serologic screening if:

◦ the source person’s HIV screening result is negative but there has been a risk for HIV exposure in the previous 6 weeks or if the source person’s HIV screening result is positive but the confirmatory antibody-differentiation assay is nonreactive or indeterminant

• PEP can be considered after 24-36 hours of the exposure with expert consultation

• Exposed persons should have an HIV antibody test at baseline, 6 weeks, 12 weeks, and 6 months after the exposure. If the 4th generation antigen/antibody test is used, testing can be done at baseline, 6 weeks, and 4 months. This testing should be done regardless of whether the

exposed person accepts or declines PEP treatment.

• If nPEP, consider PrEP after completion of the 28-day nPEP regimen for those with repeated high-risk behavior or repeat courses of nPEP

• Risk reduction and primary prevention counseling should be provided whenever someone is assessed for nPEP, regardless of whether PEP is initiated

• The Clinician Consultation Center 888.448.4911 provides timely answers for urgent exposure management and PEP. Call 9 am - 2 am EST, 7 days a week or see the online PEP Quick Guide for urgent PEP decision-making. See

quick-guide/.

• Callers are encouraged to call the PEPline with any additional or follow-up questions. Emergency calls made between 2 am and 9 am EST and during holiday hours are answered when live service resumes the following morning. See

exposure-prophylaxis-pep/.

Non-Occupational Post-Exposure Prophylaxis (nPEP) for HIV

New York State Department of Health AIDS Institute. HIV Prophylaxis Following Non-Occupational Exposure. (October 2014).

Available at Accessed December 8, 2014.

Algorithm for Evaluation and Treatment of Possible Non-Occupational HIV Exposures

Higher Risk Exposures

Lower Risk Exposures

No Risk Exposures

• Receptive and insertive vaginal or anal intercourse

• Oral-vaginal contact (receptive and insertive)

• Kissing (remote risk if blood exchanged due to sores and/or bleeding gums)

• Needle sharing

• Oral-anal contact (receptive and insertive)

• Oral-to-oral contact without mucosal damage

• Injuries (e.g., needlestick with hollow-bore needle, human bites, accidents) with

• Receptive penile-oral contact with or without ejaculation

• Human bites without blood

exposure to blood or other potentially infected fluids

• Insertive penile-oral contact with or without ejaculation

• Exposure to solid-bore needles or sharps (e.g., tattoo needles or diabetic lancets) not in

recent contact with blood

from a source known to be HIV-infected or HIV status is unknown

• Mutual masturbation without skin breakdown or blood exposure

Evaluate for factors that increase risk:

• Source person known HIV-infected with high viral load

• Non-intact oral mucosa

• Blood exposure

≤ 36 hours post-exposure

> 36 hours post-exposure

nPEP not recommended

• Genital ulcer disease or other sexually transmitted infection (STI) present

nPEP recommended

Case-by-case evaluation for nPEP. Consider expert consultation.

Clinicians can contact the Clinician Consultation Center at 888.448.4911.

Go to

nccc.ucsf.edu/clinician-consultation/post-exposure-prophylaxis-pep/

for more information.

Occupational Post-Exposure Prophylaxis (oPEP) for HIV

The Society for Healthcare Epidemiology of America. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis.

Infection Control and Hospital Epidemiology, 2013; 34(9) 875-892. Available at Accessed: October 9, 2014.

Exposed persons should have an HIV antibody test at baseline, 6 weeks, 12 weeks, and 6 months after the exposure. If the 4th generation antigen/antibody test is used, testing can be done at baseline, 6 weeks, and 4 months. Obtain complete blood count (CBC), liver function tests (LFTs), and

creatinine and estimated glomerular filtration rate (GFR) at baseline before tx with ARV medications. When given oPEP should be given for 28 days, unless the source is confirmed to be HIV-negative. Counseling at time of exposure and followup; advise on use of barrier contraception, avoidance

of blood or tissue donations, pregnancy, and if possible breast feeding to prevent secondary transmission, especially during the first 6-12 weeks after exposure.

Step 1: Evaluation of Exposure

Step 2: Determine the HIV Status of the Source

Is the source material blood, bloody fluid, other potentially infectious material

What is the HIV status of the exposure source?

(OPIM), or an instrument contaminated with one of these substances?

(OPIM = semen, vaginal secretions; cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids; or tissue)

HIV-Negative

HIV-Positive

Status Unknown

Source Unknown

Yes

No oPEP needed

What type of exposure has occurred?

No oPEP

oPEP

Determine HIV status of

oPEP generally

needed

source to guide oPEP but

recommended

not warranted

Mucous membrane, non-intact skin

Intact skin only

do not delay starting oPEP

or percutaneous exposure

7. If drug resistance is suspected, obtain expert consultation.

8. Do not delay giving oPEP while awaiting test results. If source is determined to be

No oPEP needed

Initiation of oPEP should not be delayed pending expert

HIV-negative, oPEP can be discontinued. Assessment of whether a source pt is in

oPEP recommended depending on

consultation, and, because expert consultation alone cannot

the window period between infection and positive HIV antibody, is not necessary

source HIV status

substitute for face-to-face counseling, resources should be

unless acute retroviral syndrome is clinically suspected.

available to provide immediate evaluation and follow-up care for

9. Consider oPEP where exposure to HIV-infected person likely.

6. Skin integrity is considered compromised if there is evidence of chapped skin, dermatitis, abrasion, or open wound.

all exposures.

Preferred HIV Post-Exposure Prophylaxis Regimens (All regimens are for 28 days [4 weeks])

See the Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis, (September 2013) at , the New York State Department of Health AIDS Institute

occupational post-exposure prophylaxis guidelines (October 2014) at , and the New York State Department of Health AIDS Institute. HIV Prophylaxis Following Non-

Occupational Exposure (October 2014) at All accessed October 27, 2014. The clinician is encouraged to consult an expert in PEP management when choosing a

regimen for an exposed pregnant women or in cases of exposures to virus known or suspected to be resistant to one or more antiretroviral agents. The Clinician Consultation Center provides timely answers for urgent exposure management and PEP.

Call 888.448.4911 9 am - 2 am EST, 7 days a week or see the online PEP Quick Guide for urgent PEP decision-making. See

exposure-prophylaxis-pep

for additional information.

NOTE: Some pharmacies may not “break” their bottles of ARVs which typically come in a 30-day supply. Consider ordering a complete 30-day supply to assure PEP is started in a timely manner.

PREFERRED oPEP REGIMENS

ALTERNATIVE oPEP REGIMENS

Tenofovir/Emtricitabine 300/200 mg (Truvada

) po once daily PLUS [raltegravir (Isentress

) 400 mg po twice daily OR

For alternative oPEP regimens see New York State Department of Health AIDS Institute occupational post-exposure prophylaxis guidelines

dolutegravir (Tivicay

) 50 mg po once daily]

(October 2014) at

PREFERRED nPEP REGIMEN

ALTERNATIVE nPEP REGIMENS

For alternative nPEP regimens see New York State Department of Health AIDS Institute non-occupational post-exposure prophylaxis guidelines

Tenofovir/Emtricitabine 300/200 mg (Truvada

) po once daily PLUS [raltegravir (Isentress

) 400 mg po twice daily OR

(October 2014) at

dolutegravir (Tivicay

) 50 mg po once daily]

exposure/

10. USPHS Guidelines list only the raltegravir regimen as preferred. See

Antiretrovirals Recommended for oPEP and nPEP (Dosage Forms and Important Points)

Refer to Appendix B of the Adult/Adolescent Antiretroviral Guidelines for a complete and updated source for antiretroviral medications to include: dosing, renal or hepatic insufficiency dosage adjustments, side effects, drug interactions, and warnings/condraindications.

Available at

DRUG

DOSAGE FORMS

IMPORTANT POINTS

• Take with or without food

• Take 2 hrs before or 6 hrs after certain medications (e.g. cation-containing antacids or laxatives, sucralfate, oral iron or calcium supplements, multivitamins with minerals) containing

Dolutegravir (DTG, Tivicay

)

50 mg tab

polyvalent cations (e.g. Mg, Al, Fe, Ca). DTG may be taken with calcium or iron supplements if taken together with food.

• Adverse Effects: headache and insomnia most common. Hypersensitivity reaction including rash, constitutional symptoms and organ dysfunction (e.g. liver injury) have been reported.

• Take with or without food

Emtricitabine (FTC, Emtriva

)

200 mg cap, 10 mg/mL oral solution (soln)

• Abrupt withdrawal can cause chronic active HBV flares

• Adverse effects: generally well-tolerated, ↑ pigmentation of palms/soles (> in black and Hispanic pts)

• Take with or without food

• Evidence suggests polyvalent cations may ↓ RAL levels. Avoid Al or Mg-containing antacids. No separation needed when given with CaCO3 antacids. Consider taking RAL 2 hrs

Raltegravir (RAL, Isentress

)

400 mg tab, 25 and 100 mg chewable tabs

before or 6 hrs after other medications containing polyvalent cations (e.g., Mg, Al, Fe, Ca) pending more data regarding interactions.

• Adverse effects: diarrhea, nausea, headache, and pyrexia; ↑ ALT, AST, creatine phosphokinase; myopathy and rhabdomyolysis have been reported, rare severe skin reactions (SJS/

TEN) and systemic HSR with rash, and constitutional symptoms +/- hepatitis

• Take tabs with or without food; take powder with food

• Abrupt withdrawal can cause chronic active HBV flares

Tenofovir (TDF, Viread

)

300, 150, 200, 250 mg tab, 40 mg/1g oral powder

• Do not use for PEP in pts with estimated CrCL < 60 mL/min

• Adverse effects: flatulence, headache, renal insufficiency, Fanconi Syndrome (rare), ↓ PO4

Tenofovir/Emtricitabine (TDF/FTC, Truvada

)

Tenofovir 300mg/Emtricitabine 200 mg tab

See individual components