CDC MMWR Recommendations and Reports September 30, 2005 / Vol 54 / No. RR-9 Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis 1 2 3 HCP health-care personnel HCP PEP post-exposure prophylaxis percutaneous injury source person source person health-care provider(s) health-care provider(s) ZDV AZT 1. HCP 2. HIV 3. PEP HIV 4. HIV 5. 6. HIV PEP HIV HCP 7. HIV PEP 8. HIV PEP 9 HCP 10. HIV PEP APPENDIX 1
HCP HIV 01 05 2 HIV HIV adherence urgent medical concerns 1996 1 HIV 2 update HIV HIV HBV HCV 1. HCP HCP health-care settingspaid unpaid HIV 2
2. HIV HIV 2,3,7 HCP HIV 0.3% 95% confidence interval [CI] = 0.2%--0.5% 7 HCP HIV 0.09% (95% CI = 0.006%--0.5%) 3 HIV HIV HIV HIV 3 AIDS HIV 100 AIDS syncytia HIV HIV 3 source person HIVRNA HIV HIV 1500copies/ml 3. PEP HIV HIV 5 HIV PEP 2 3 1 2 3
1 HIV less severe more severe HIV class 1 2 recommend 3 recommend HIV class 2 3 recommend HIV HIV 2 consider HIV HIV 2 consider HIV 2 HIV 2007 TDF+FTC 1 3 HIV 2007 2 less severe more severe HIV Class 1 HIV HIVRNA 1500 /ml HIV Class 2 HIV AIDS HIV HIVRNA HIV HIV HIV HIV consider HIV 4
2 HIV small volume large volume HIV 2 2 recommend class 1 consider HIV class 2 2 recommend 3 recommend HIV HIV 2 consider HIV 2 consider HIV 2 HIV 2007 TDF+FTC 1 3 HIV 2007 2 small volume a few drops large volumemajor blood splash HIV Class 1 HIV HIVRNA 1500 /ml HIV Class 2 HIV AIDS HIV HIVRNA HIV HIV HIV splash from inappropriately disposed blood HIV consider HIV 5
HIV PEP 4 3 HIV PEP 3 HIV HIV HIV PEP PEP HIV PEP HCP HIV 17-47% 4 15-17 19 20 National Surveillance System for Health Care Workers (NaSH) CDC 1995 12 2004 12 921 HCP 401 46.9% 1 26.5% 22.8%28 503 HCP361 24% PI HIV HIV HCP 3-5 PI NNRTI 13 24-33 4 6
3 HIV NRTI Zidovudine AZT Lamivudine 3TC Stavudine d4t Didanosine ddi Emtricitabine FTC Tenofovir TDF NNRTI Efavirenz EFV Stevens-Johnson PI Indinavir IDV Nelfinavir NFV Ritonavir RTV Saquinavir SQV Fosamprenavir FPV Atazanavir ATV Lopinavir/rtv LPV FI Enfuvirtide T-20 7
4 PI PI 90% PI midazolam triazolam PI dihydroergotamine ergotamine ergonovine methylergonovine PI cisapride HMG-CoA Atrovastatin lovastatin simmvastatin pimozide PI fluticasone Fluticasone fluticasone Herbal products St. John s wort PI 5 efavirenz voriconazole voriconazole EFV EFV dihydroergotamine ergotamine ergonovine methylergonovine EFV cisapride Herbal products St. John s wort efavirenz 8
HIV PEP HIV PEP primarily empiric 34 HIV 3 HIV PEP 13 14 HIV 3 2 HIV 13 14 PI NRTI PEP 3 PEP 3 4 2 viable2 4 3 4 35 HIV HIV 2 3 2 1 2 HIV PEP 36 37 PEP HIV 36 38-40 PEP HIV 6 6 38 d4t/3tc/sqv/rtv AZT ddc 1 AZT 3TC Phenotype 3TC AZT d4t NNRTI 95 AZT /3TC/IDV 6 ddi/d4t/nvp 8 ddi d4t/nvp 24 HIV 3 NNRTI 9
37 CD4 PEP 1 2 PEP 41 6 HCP HIV PEP PEP HIV 1 1992 AZT/ddI 0.5 23( ) 23( ) AIDS 2 1996 AZT /ddi AZT 1.5 45 97 3 1997 AZT (d4t)/3tc/idv 1.5 40 55 AIDS 4 1998 AZT /ddi/3tc/idv 0.7 70 83 AIDS 5 1999 ddi/d4t/nvp 2 42 100 AIDS 6 2001 AZT /3TC/IDV 95 24 90 AIDS ddi/d4t/nvp 1.6 2 AZT/ddI 48 AZT 3 AZT/3TC/IDV 48 d4t/3tc/idv 5 AZT/3TC 1 ddi/d4t/nvp 3 ddi 6 AZT /3TC/IDV 1 ddi/d4t/nvp 8 ddi 10
4. HIV HIV 3 AZT NRTI EFV IDV IDV IDV HIV HIV HIV d4t/ddi 5. 1985 HCP 42 2002 71 95% 2002 43 3 HIV 6. HIV PEP NaSH 1995 6 2004 12 95 PEP 28,010 1995 6 2004 12 28,010 25,510 % 25,510 HIV 1,350 5.3% HIV 15,301 60.0% HIV 8,859 34,7% HIV 1,350 PEP 788 58.4% 1 909 67.1% 11
4 6 289 38.1% PEP 788 647 21 PEP 317 49% PEP 27 21 PEP 317 49% PEP 27 HIV PEP 2 HIV PEP 44-47 2004 21 84% HIV PEP 2 2004 PEP 39 30 76.9% 3 2 227 104 45.8% 3 2001 1996 6 2000 11 707 HIV 445 PEP 1995 6 2004 12 1,350 HIV 788 PEP 2000 12 2004 12 343 1995 6 1996 6 PEP PEP PEP 2001 1 1/343 1995 6 1996 6 PEP 1996 6 2000 11 4.5 445 4.5 100 343 100 243 2000 12 2004 12 PEP 1/243 12
HIV HCP PEP 7. HIV PEP HCP HIV PEP 1 2 PEP PEP HIV PEP window period window period 39 HIV HIV HIV PEP PEPHIV HIV PEP HCP 72 PEP PEP within hours PEP 2 3 2 PEP 2 PEP 4 AZT PEP 4 8. HIV PEP HIV PEP PEP PEP HIV PEP 13
PEP HIV CD4 HIVRNA 1 HIV PEP PEP PEP 2 HIV 2 2 AZT3TC AZT FTC d4t 3TC d4t FTC TDF3TC TDF FTC d4t+ddi 3 4 HIV 3 4 HIV PEP 3 2 3 4 IDV NFV EFV ABC 3 4 PI 1 LPV/rtvatazanavir RTV fosampremavirrtv IDV RTV SQV NFV PIEFV EFV NRTI 3TC FTC ddi T-20 T-20 T-20 gp41 gp41 T-20 PEP HIV ABC 2 4 9% Delavirdine ddc 1 3 d4t ddi NVP 53-55 HIV certain institutions PEP 14
Box 1 Box 1 HIV 24-36 HIV HIV HIV HCP PEP PEP HCP PEP PEP HIV PEP PEP PEP PEP common PEP 9 HCP HCP HIV 6 6 12 6 HIV HCV HCV 12 HIV HCV 12 6 HIV 56 57 12 HCPHIV HIVRNA 15
HIV HIV HCP HIV HIV HCP HIV PEP PEP 2 CBC PI Indinavir PEP PEP HCP HCP PEP HCPBox2 PEP HIV HIV HIV HCPHCP Box 2 HIV HCP 16
HCP 2 donation 6 12 PEP 72 10. HIV PEP 17
APPENDIX 2Basic Regimen 2 AZT 3TC AZT 1 600mg 2 1 600mg 3 3TC 1 300mg 1 2 1 2 2 1 AZT300mg 3TC150mg HIV PEPPEP 3TC 3TC HBV AZT FTC AZT 1 600mg 2 1 600mg 3 FTC 1 200mg 1 FTC 3TC 3TC AZT FTC 40 FTC 3TC Caucasians 3% 3TC FTC HBV TDF 3TC TDF 1 300mg 1 3TC 1 300mg 1 2 3TC TDF TDF Atazanavir LPV/rtv TDF Atazanavir Atazanavir 300mg ritonavir 100mg TDF 3TC HBV TDF TDF FTC TDF 1 300mg 1 FTC 1 200mg 1 Truvada TDF 300mg FTC 200mg 1 1 18
TDF FTC HBV TDF 22 d4t 3TC d4t 1 80mg 2 60kg 60mg 2 3TC 1 300mg 1 2 3TC d4t 3TC d4t 3TC 3TC HBV d4t FTC d4t 1 80mg 2 60kg 60mg 2 FTC 1 200mg 1 FTC d4t FTC FTC HBV 3TC ddi 3TC 1 300mg 1 2 ddiec 1 400mg 1 2 60kg 250mg 3TC ddiec 1 1 3TC ddi TDF 3TC HBV FTC ddi FTC 1 200mg 1 ddiec 1 400mg 1 2 60kg 250mg FTC ddi TDF FTC HBV 19
3Expanded Regimen 3 LPV/rtv lopinavir/ritonavir LPV/rtv 1 LPV133mg RTV33mg 1 6 2 LPV/rtv HIV LPV/rtv 4 1 2 1 2 1 4 23 Atanazavir ATV ritnonavir ATV 400mg 1RTV100mg 300mg 1 ATV TDF ATV300mg RTV100mg ATV 1 1 ATV 3TC 4 2 H2 12 RR HIV ATV RTV Fosamprenavir FPVritonavir FPV 1400mg 2 RTV200mg FPV1400mg RTV200mg 2 1 FPV RTV 1 1 FPV FPV RTV HIV Indinavir IDV ritonavir IDV1600mg RTV200mg 2 IDV RTV 1 2400m 3 IDV HIV IDV 4 ddi PEP 20
Nelfinavir NFV NFV2500 mg 2 NFV NFV 4 Efavirenz EFV EFV600mg 1 EFV 1 1 EFV HIV 4 PEP Nevirapine NVP PEP Stevens-Johnson HIV HIV Delavirdine DLV Abacavir ABC 6 HIV Zalcitabine ddc 1 3 HIV Enfuvirtide T20 Fuzeon T20 1 90mg 1 2 T20 T20 1 2 HIV HIV gp41 T20 21
1. HIV A. B. C. D. E. A D F. B C 2. HIV PEP 1 A. 7 B. 14 C. 21 D. 28 E. 2 3. PEP 1 A. 2 B. 24-48 C. 4. 1 A. HIV B. PEP C. HIV D. PEP E. A D 5. PEP HIV 1 A. NRTI B. NNRTI C. PI D. A B E. B C F. A C 6. HIV HCP A. Efavirenz EFV B. Zidovudine AZT C. Nelfinavir NFV D. Tenofovir TDF 22
7. A. B. 8. HCP PEP A. B. 9. HIV 1 A. B. C. D. Abraded E. C D F. A B 10. 12 A. HIV B. PEP C. HIV HCV HCV D. 1. E; 2. D; 3. C; 4. E; 5. E; 6. A; 7. B; 8. B; 9. E; 10. C 23