December 8, 2013
The estimable Paul Sax, M.D., from Brigham and Women's Hospital (a leading force in the break-the-routine CD4+ monitoring movement) called them, "The world's most outdated guidelines." Many health care providers demonstrated their disdain by ignoring them. Rumors swirled that an update was in the works. Now it has happened: The U.S. Public Health Service guidelines for the management of occupational exposures to HIV have, finally, been updated and modernized.
Much has occurred since the last version of the post-exposure prophylaxis (PEP) guidelines were issued back in 2005. Foremost, a slew of better drugs for PEP have come along since the last guidelines recommended drugs such as zidovudine and lopinavir/ritonavir (Kaletra). Further, the guidelines' peculiar instruction to assess the severity of the exposure and administer either a two- or three-drug regimen depending on whether the risk of infection was a little or a lot was considered strange even then. Also, in the intervening years, we have come to better understand the determinants of the transmission of HIV.
The new guidelines, published in the journal Infection Control and Hospital Epidemiology in September, catch up with science and practice. Exposures warranting PEP are responded to with a very reasonable regimen of tenofovir/emtricitabine and raltegravir -- mirroring the NY state public health guidelines, which many followed in lieu of a U.S. Public Health Service update. A list of alternatives is included for special circumstances (e.g., renal insufficiency in the exposed worker). There is also a nice update to follow-up HIV testing, reflecting the availability of the newer testing options such as the combination p24 antigen/antibody assay.
People pay attention to guidelines and some are bound to them. That recommendations for the management of those exposed to HIV in the workplace had become anachronistic rendered them meaningless and of little use. Worse, they sowed confusion. The updated PEP guidelines are on target and will spare exposed workers the unnecessary adverse effects of older medications. Moreover, the guidelines advocate an approach that preaches what we practice. That is what those potentially exposed to HIV in the workplace need and deserve.
What are some other top clinical developments of 2013? Read more of Dr. Wohl's picks.
David Alain Wohl, M.D., is an associate professor of medicine in the Division of Infectious Diseases at the University of North Carolina and site leader of the University of North Carolina AIDS Clinical Trials Unit at Chapel Hill.
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