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NCBI Bookshelf. View in own window. Despite the availability of prevention measures, exposures occur that pose the risk of transmission. Fortunately, with rapid initiation of PEP, infection can be blocked. HIV transmission can be prevented through use of barrier protection during sex e.

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The first dose of PEP should be administered within 2 hours of an exposure ideal and no later than 72 hours after an exposure. In addition to clinical recommendations, this guideline details selected good practices and highlights laws and legal considerations that are pertinent in delivering PEP care.

Goals: This guideline aims to achieve the following goals: Prevent HIV infection in individuals who experience a high-risk exposure. Reinforce that HIV exposure is an emergency that requires rapid response, with immediate administration of the first dose of PEP medications. Ensure prescription of PEP regimens that are effective and well tolerated. Assist clinicians in recognizing and addressing challenges to successful completion of a PEP regimen. Detail the baseline testing, monitoring, and follow-up that should accompany prescription of a day course of PEP.

How to use this guideline: This guideline is organized to support rapid location of key topics, such as when to initiate PEP, how to evaluate whether continuation of PEP is necessary based on specific risk factors, source testing, how to choose and prescribe a PEP regimen, and recommendations for follow-up care for exposed individuals. In formulating recommendations for NYS, this Committee balanced the strength of published evidence regarding efficacy and timing of initiation of the PEP regimen.

Factors that increase the risk of transmission: Many factors that contribute to HIV infection are shared by the 4 PEP scenarios outlined below. HIV transmission risk is low and often negligible when the source of the exposure has a low or undetectable viral load [ Rodger, et al.

Data are insufficient to make recommendations regarding HIV transmission via breastfeeding. The risk of HIV transmission in a healthcare setting has been reported as 0. With the use of potent antiretroviral ARV medications that have increased bioavailability, it is pd the use of a 3-drug PEP regimen would ificantly reduce this risk further. In the current era of increasing viral suppression in patients with HIV, early and appropriate PEP initiation, and improved infection control protocols, these rates may be lower.

In addition to their internal findings, the authors compared their to a calculated overall HIV seroconversion rate of 0. The mean risk may be ificantly higher in cases of percutaneous exposure in which more than 1 risk factor is present e. Ensure use of and compliance with devices with safety features.

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Eliminate needle recapping. Ensure safe handling and prompt disposal of needles in containers for sharps disposal. Provide ongoing education about and promote safe work practices for handling needles and other sharps. Even when effective prevention measures are implemented, exposures to blood and bodily fluid still occur. Employers of personnel covered by the OSHA Bloodborne Pathogen Standard are obligated to provide post-exposure care, including prophylaxis, at no cost to the employee.

Parenteral Exposure Risk: Needle sharing during injection drug use: 63 Percutaneous needlestick : Factors that increase risk of transmission through parenteral exposure: Hollow-bore needle Deep injury penetration Needle placed in an artery or vein [ Cardo, et al. HIV transmission has been documented, but rarely.

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Accurate estimates of risk are not available. It is prudent to consider non-occupational PEP for receptive oral sex with ejaculation, although discussion about the low risk should occur. Factors that increase risk of transmission through sexual exposure: Source with known HIV who is not taking ART or has incomplete viral suppression; risk of transmission increases with higher source HIV viral load levels [ Quinn, et al.

Trauma at the site of exposure. Blood exposure, which can be minimal and therefore not recognized by the exposed individual; if the exposed individual reports frank blood exposure, PEP is indicated. Lack of male circumcision [ Bailey, et al. Non-intact oral mucosa e. Factors that increase risk of transmission through other exposures: Source with high HIV viral load [ Quinn, et al.

Activity involving exposure to blood.

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Sexual exposures consensual : Exposures that may prompt a request for non-occupational PEP include condom slip or breakage; lapse in condom use by serodiscordant or unknown status partners; or other episodic exposure to blood or other potentially infectious body fluids, including semen, vaginal secretions, or body fluids with visible blood contamination.

In addition to the viral load of a source with HIV, other factors that influence transmission and acquisition risk include [ Sultan, et al. Type of sexual exposure, i. Circumcision status. Condomless receptive anal sex with and without ejaculation carries a risk of 1.

Condomless insertive anal intercourse carries a risk of 0. In one European study, the risk associated with condomless receptive and insertive vaginal intercourse was 0. Information for patients is available about correct male insertive and female receptive condom use. Needle sharing and needlestick injuries: Needle sharing among injection drug users is a common reason to request PEP, as the associated risk has been estimated to be as high as 63 per 10, exposures based on a study among injection drug users in Thailand [ Hudgens, et al.

For this reason, PEP should always be considered in this scenario provided the potential exposure was within 72 hours. Another route of exposure that prompts requests for PEP is needlestick injury in the community. Factors associated with risk from needlestick injuries include the potential source of the needle, type of needle, presence of blood, and skin penetration. Individuals who incur needlestick injuries from discarded needles are often concerned about potential HIV exposure. Consideration of potential risk from discarded needles should include the prevalence of HIV in the community or facility where the exposure occurred and the prevalence of injection drug use in the surrounding area.

However, the risk of HIV transmission through exposure to dried blood found on syringes is extremely low [ Zamora, et al. Discarded needles should not be tested for HIV because of low yield and the risk of injury to personnel involved in Sex Dating Struble testing. Vaccination to prevent tetanus and administration of hepatitis B vaccine are indicated for needlestick injures resulting in puncture wounds, based on immunization history and hepatitis B virus status of the source [ Bader Sex Dating Struble McKinsey ; Stobart-Gallagher ]. Bite wounds: An estimatedhuman bites occur annually in the United States in a variety of settings [ American Academy of Pediatrics ].

Although possible, HIV transmission through bites is thought to be extremely rare.

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Though many reported instances of bites have occurred, few cases of associated HIV infection have been established. Cases of possible HIV transmission have been documented following bites in adults exposed to blood-tinged saliva [ Vidmar, et al. A systematic review found no cases of HIV transmission through spitting and 9 possible cases of HIV transmission through a bite 6 occurred between family members, and 2 involved untrained first responders who placed their fingers in the mouth of an individual who is experiencing a seizure.

Only 4 of the 9 cases were confirmed or classified as highly plausible [ Cresswell, et al. A bite wound that in blood exposure should prompt consideration of PEP. When a human bite occurs, it is possible for both the individual who was bitten and the biter to incur blood exposure see scenarios listed below.

Use of PEP in such a case may be indicated if there is ificant exposure to deep, bloody wounds.

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A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted. Blood exposure to the bitten individual: When the biter has blood in his or her mouth e.

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Prevention of non-occupational exposure: Transmission of HIV can be prevented through use of condoms and safer drug injection techniques. HIV infection can be prevented with use of antiretroviral medications as PrEP to protect an individual who engages in behaviors that may result in exposure to HIV. Statistics on sexual assault in the United States show high rates of attempted or completed rape among several populations, including cisgender women, men, children, and transgender individuals: Perpetrators of intimate partner violence are not likely to use condoms or use condoms inconsistentlyare likely to force sexual intercourse without a condom and to have sexual intercourse with other partners [ Raj, et al.

PEP is the only proven method of reducing HIV acquisition after exposure, and it should be offered in cases of sexual assault. There are published reports of HIV seroconversion following sexual assault [ Murphy, et al.

Although there is evidence to support HIV prophylaxis for perinatal exposure, there are no randomized clinical trials of PEP in children beyond the perinatal period. Types of exposures that may be reported in children include sexual assault, needlesticks, or bite from who has HIV, but as noted below, this last type of exposure is no longer likely to occur. Biting: Biting is a common occurrence among young children and in daycare settings.

The levels of HIV detected in saliva alone are very low. The few documented cases of possible HIV transmission following bites occurred in adults exposed to blood-tinged saliva [ Vidmar, et al.

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As mentioned ly, a recent systematic review found no cases of HIV transmission through spitting and 9 possible cases of transmission through biting [ Cresswell, et al.

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