{"id":2512,"date":"2012-03-01T22:07:51","date_gmt":"2012-03-02T03:07:51","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=2512"},"modified":"2015-06-04T15:14:55","modified_gmt":"2015-06-04T19:14:55","slug":"post-exposure-prophylaxis-the-worlds-most-outdated-hiv-guidelines-and-what-to-do-about-them","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/post-exposure-prophylaxis-the-worlds-most-outdated-hiv-guidelines-and-what-to-do-about-them\/2012\/03\/01\/","title":{"rendered":"Post-Exposure Prophylaxis, the World&#8217;s Most Outdated HIV Guidelines, and What To Do About Them"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/03\/pep-comics1.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-full wp-image-2514\" title=\"pep comics\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2012\/03\/pep-comics1.jpg\" alt=\"\" width=\"202\" height=\"280\" \/><\/a>Every time I cover HIV prevention in a lecture, it&#8217;s always kind of embarrassing to cite the &#8220;official&#8221; post-exposure prophylaxis (PEP) guidelines, which are <a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr5402a1.htm\" target=\"_blank\">here<\/a> (non-occupational) and\u00a0<a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/rr5409a1.htm\" target=\"_blank\">here<\/a> (occupational).<\/p>\n<p>That&#8217;s right, they were last updated in 2005, the year of Hurricane Katrina.<\/p>\n<p>Yes &#8212; <em>more than six years ago. <\/em>The alternative choices seem particularly curious (read: don&#8217;t do it) today &#8212; indinavir\/ritonavir or efavirenz for PEP? You&#8217;ve got to be kidding me.<\/p>\n<p>Because here&#8217;s a short list of what&#8217;s happened since then related to the HIV prevention front:<\/p>\n<ul>\n<li><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1105243\" target=\"_blank\">HPTN 052<\/a><\/li>\n<li><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa0908492\" target=\"_blank\">An HIV vaccine study<\/a> that, marginal efficacy aside, at least gave us a sense of &#8220;community risk&#8221; in a low-moderate prevalence area<\/li>\n<li><a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1011205\" target=\"_blank\">iPrEx<\/a><\/li>\n<li>Landmark studies in perinatal prevention, such as <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa0907736\" target=\"_blank\">this one<\/a><\/li>\n<li>That great wave of HIV drug development, which included darunavir, maraviroc, raltegravir, and etravirine<\/li>\n<\/ul>\n<p>No, there&#8217;s not been much new on occupational risk of HIV acquisition, which fortunately remains incredibly rare &#8211;and has always been a relatively data-free zone. (For the record, this is pretty much it <a href=\"http:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMoa1011205\" target=\"_blank\">here.<\/a>)<\/p>\n<p>So what&#8217;s an ID\/HIV specialist to do?<\/p>\n<p>I&#8217;ve been told that the next round of PEP guidelines is in development, but frankly the existing guidelines have been out of date for so long that <em><a href=\"http:\/\/1001-songs.blogspot.com\/2012\/02\/40-years-ago-this-month-todd-rundgrens.html\" target=\"_blank\">something\/anything<\/a><\/em> has to be done.<\/p>\n<p>Hence I welcome the imminent publication of <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22267017\" target=\"_blank\">this paper<\/a> on the use of tenofovir\/FTC and raltegravir for non-occupational post-exposure prophylaxis.<\/p>\n<p>Yes, the study is small, and there&#8217;s no control group; furthermore, given the rarity of transmission, it can&#8217;t really estimate the preventive efficacy of this intervention &#8212; we&#8217;ll probably never have that.<\/p>\n<p>But it provides at least some support behind what we&#8217;ve been doing now for several months, which is frequently replacing lopinavir\/r with raltegravir &#8212; leading to much better tolerability of the PEP regimen.<\/p>\n<p>And our hospital is about to make it official. From my colleague <a href=\"http:\/\/physiciandirectory.brighamandwomens.org\/directory\/profile.asp?dbase=main&amp;setsize=1&amp;pict_id=0005337\" target=\"_blank\">Sigal Yawetz<\/a>, who heads up our PEP program, comes the following:<\/p>\n<blockquote><p>First line empiric therapy, not pregnant, no renal problems:\u00a0tenofovir\/FTC, raltegravir<\/p>\n<p>First line therapy, pregnant (or breast feeding, continues to breast feed though not recommended): zidovudine\/3TC,\u00a0lopinavir\/r<\/p>\n<p>First line therapy, abnormal renal function: zidovudine\/3TC,\u00a0raltegravir<\/p>\n<p>For any exposure to known infected person: ART to be selected by HIV expert<\/p><\/blockquote>\n<p>There &#8212; PEP Guidelines updated!<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Every time I cover HIV prevention in a lecture, it&#8217;s always kind of embarrassing to cite the &#8220;official&#8221; post-exposure prophylaxis (PEP) guidelines, which are here (non-occupational) and\u00a0here (occupational). That&#8217;s right, they were last updated in 2005, the year of Hurricane Katrina. Yes &#8212; more than six years ago. The alternative choices seem particularly curious (read: [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,4,5,8,9],"tags":[397,571,706,742,779,902],"class_list":["post-2512","post","type-post","status-publish","format-standard","hentry","category-antiretroviral-rounds","category-hiv","category-infectious-diseases","category-patient-care","category-policy","tag-guidelines","tag-lopinavirr","tag-pep","tag-post-exposure-prophylaxis","tag-raltegravir","tag-tdfftc"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2512","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=2512"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/2512\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=2512"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=2512"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=2512"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}