HIV Post-Exposure Protocol
The Pediatric Infectious Disease Services at UMass Memorial Children's Medical Center answers many questions about the risks of developing HIV after various types of exposures. Our staff is also able to make recommendations about treatment to prevent HIV infection after such exposures occur.
Early treatment after HIV exposure is designed to limit viral replication, so rapid initiation of post-exposure prophylaxis (PEP) is important. Recommendations are that PEP start as soon as possible after exposure - optimally within hours. For this reason, we recommend that emergency rooms have ready access to these medications and that the first doses of PEP be administered before patients leave the emergency room. Delays in obtaining medications because of insurance problems, pharmacy hours, nonavailability of medications or transportation issues can render PEP ineffective.
UMass Memorial offers the links on the right to help physicians evaluate their patients and to answer questions about PEP.
Staff and Contact Information
A pediatric infectious disease specialist is available by telephone to answer questions about exposure to HIV, risks of infection and post-exposure prophylaxis. Call 508-334-1000 and ask to page the pediatric infectious disease physician on call.
To provide optimal and specific advice, we ask that physicians review the history of the patient, and the source and nature of the exposure on the call.
Pediatric Immunology/Rheumatology Specialists
Risk of Infection
The risk of becoming infected with HIV depends on the type of exposure:
- The risk for a health care worker after a percutaneous exposure to HIV-infected blood is 0.3 percent; risks may be higher if there is a larger quantity of blood, direct entry of a contaminated needle into an artery or vein, or a deep injury; it may also be higher if the blood is from a terminally ill patient with a very high viral load.
- The risk for a health care worker after mucous membrane exposure to HIV-infected blood is 0.09 percent.
- The risk after sexual assault is unknown but there is a 1/500 chance of a female becoming infected after consensual vaginal intercourse with an HIV-infected male; some males have been found to be "high-risk" HIV transmitters.
- There is a 1/50 chance of becoming infected after anal intercourse.
- The risks are higher if trauma is involved with anal or vaginal intercourse, or if there is exposure to nonintact mucosa.
- Retrospective studies in health care workers have indicated that the risk for HIV infection was reduced by approximately 80 percent by using AZT alone as post exposure prophylaxis.
Protocol for the Emergency Department Provider
1. Treat site of exposure (i.e., clean wound, flush mucous membrane).
2. Obtain information regarding the exposure incident. Examples:
- Was the exposure from a needle, sexual contact, bite or other agent?
- What is known about the person who caused the exposure (hepatitis C/HIV status)?
- Was there visible blood in needle/syringe (fresh/dried)?
3. Obtain information regarding the health status of the patient, including height, weight, general health, allergies, ability to take tablets versus liquid and status of hepatitis B vaccination.
4. Consult the UMass Memorial pediatric infectious disease physician on call (call 508-334-1000 and ask for the physician to be paged). The pediatric infectious disease specialist will assist in making decisions:
- Whether or not to offer PEP
- Medication treatment (dosing schedule for antiretroviral drug attached)
- Whether hepatitis B prophylaxis is indicated (hepatitis B immune globulin)
5. If the patient is seen between 9 am and 5 pm, Monday through Friday, the pediatric infectious disease physician will contact the pediatric HIV nurse for appropriate follow-up care.
6. Obtain the following blood labs:
- HIV antibody (requires signed consent)
- Hepatitis B antibody to core and surface antigen
- CBC with differential
- Hepatitis C antibody
- SGOT, SGPT
Please note: If at all possible, test the person whose blood or fluids were the agent of exposure as well.
7. If it is decided that PEP is needed, administer the first dose of antiretroviral drugs to the patient in the Emergency Room. PEP is most effective when started within hours of the exposure.
8. Provide the patient with:
- Patient information sheet for PEP
- Medication information sheet
- Prescription for PEP medications; direct the family to fill the prescriptions as soon as possible and confirm the next time medication is to be administered
- Hepatitis B immune globulin and hepatitis B vaccine if the patient has not received hepatitis B vaccine
9. Upon consulting with a pediatric infectious disease specialist, if necessary, provide the patient/family with the telephone number for the Division of Pediatric Infectious Disease 508-856-3947. Ask them to contact the office the following weekday and speak with one of the pediatric HIV nurses. A follow-up appointment in the Pediatric Infectious Disease Clinic will be scheduled at that time.
10. Emphasize to the patient that side effects may occur from PEP treatment, but they should call us before stopping treatment.
Pediatric Medication Dosing
Dosage Guidelines for Post-exposure Prophylaxis for HIV
AZT (Zidovudine, Retrovir)
Dose: 240 mg/ m2 per dose BID
Available in capsules 100 mg, tablets 200 mg and 300 mg, and syrup 10mg per ML
Common side effects associated with AZT include nausea, headaches, insomnia, muscle aches and general feeling of fatigue. These side effects often improve with continued treatment. The most serious potential side effects are anemia (a decrease in the number of red blood cells) and/or neutropenia (a decrease in the number of white blood cells).
3TC (Lamivudine Epivir)
Dose: Up to 12 years - 4 mg per kg BID (Max 150 mg BID)
Greater than 12 years - 150 mg BID
Available in tablets 150 mg and solution 10 mg per ML
3TC has been tolerated quite well. Potential side effects are generally mild including headache, nausea, diarrhea, abdominal pain and insomnia.
AZT - 3TC (Combivir)
Dose:
1 tablet BID
Available in tablet combination 300 mg AZT/150 mg 3TC
The most common side effects associated with the use of combivir include headache, nausea and tiredness. Less common side effects include diarrhea, vomiting, decreased appetite, muscle or nerve pain, difficulty sleeping, cough, fever and dizziness. Occasional side effects include stomach pain or cramping, upset stomach, rash, anemia (a decrease in the number of red blood cells), neutropenia (a decrease in the number of white blood cells) and joint pain. A rare side effect is the development of inflammation and enlargement of the liver. Taking Combivir with food will help decrease nausea and headache.
Nevirapine (Viramune)
2 does only
Dose 1 - 120 mg/ m2 immediately (maximum 200 mg)
Dose 2 - 120 mg/ m2 48 hours after initial dose
The most common side effects associated with the use of nevirapine are rash, fever and headache. Occasional side effects are nausea, diarrhea, abdominal pain, sores in and around the mouth, numbness and tingling in the arms and legs, muscle pain and hepatitis (inflammation of the liver). Severe and life threatening hepatitis and skin reactions have occurred in a small percentage of patients treated with nevirapine. These two side effects have not been reported with administration of only two doses. Contact the Pediatric Infectious Disease office at any time if a rash is noted. Nevirapine can be taken with or without food.
Patient Information
Post-exposure Prophylaxis for HIV in Children and Adolescents
Adapted from the Post-exposure Prophylaxis (PEP) for HIV Treatment Protocol
UMass Memorial Medical Center
Department of Medicine - Division of Infectious Disease
Revised 5/2007
HIV is the virus that causes AIDS. It can be transmitted from one person to another through exposure of blood or body fluids that contain the virus. Fluids that contain the virus are blood, semen, vaginal fluid and breast milk. Sweat, tears, saliva, urine and stool do not contain significant quantities of HIV unless there is blood mixed with them. HIV is not transmitted through intact skin. Bites very rarely transmit HIV. No HIV infections have been documented from injuries from needles discarded in public settings. Post-exposure prophylaxis medications are not routinely given for these situations.
The principal risks of acquiring HIV infection are through unprotected sexual contact, an infant born to an HIV infected woman, breast feeding and percutaneous (through the skin) exposure to an infected person's blood.
It is not possible to completely eliminate the risk that someone will develop HIV infection after they have had a significant exposure to the virus. However, studies in health care workers who have had needle stick exposures have shown that post-exposure treatment with anti-HIV medications can reduce the risk by about 80 percent. This means that there is a greatly decreased chance that someone will develop HIV infection.
If the risk of infection is high, it is important that prophylaxis with anti-HIV medications be started immediately. There may be side effects associated with the use of these medications. These are detailed in the information pages given to you. If side effects occur, please contact your primary care physician or the pediatric infectious disease service at UMass Memorial before stopping medications. Contact information is below.
Current recommendations state that medications used for PEP to prevent HIV infection be taken for 28 days. Blood tests will be done while taking these medications to monitor side effects. The decision as to whether someone should take post exposure prophylaxis for HIV infection requires weighing the seriousness of the exposure to the virus verses the risk of possible side effects from the post exposure prophylaxis medications.
UMass Memorial staff will work with the primary care physician to determine appropriate follow-up care.
If you have any questions or concerns, please contact the Pediatric Infectious Disease Clinic at 508-856-3947 between 9 am to 5 pm, Monday through Friday. After 5 pm, weekends or holidays, contact the pediatric infectious disease physician on-call through the page operator at 508-334-1000.