Antiretroviral prophylaxis following

Antiretroviral prophylaxis following
occupational exposure has been a
standard of care for health workers
since the 1980’s. Prophylaxis following
sexual exposure and other exposures
including injecting drug use has been
extensively considered and debated.
Practical guidelines and policy
recommendations for non-occupational
HIV prophylaxis must consider the
limitations of current scientific
knowledge and lack of definitive
evidence concerning efficacy to support
such recommendations.
Post-exposure prophylaxis should be
considered following non-occupational
exposures that include sexual assault,
needle sharing, trauma involving human
bites where there is exchange of
blood, condom breakage or other
exposures. Because there are no
randomized, placebo-controlled
clinical trials on which to definitively
base recommendations, current
recommendations are based on best
practice evidence and the considered
opinion of experts in this field. Several
studies also support the feasibility of
post-exposure prophylaxis1 .
There are many factors to consider
when deciding whether to implement
post-exposure prophylaxis or not.
A general and simple approach is that
whenever possible, risk assessment
and initiation of post-exposure
prophylaxis should occur in settings
where voluntary counselling and testing
services as well as HIV clinical
expertise are available or easily
accessible by referral. Clients should be
evaluated as soon as possible in order
for therapy to be initiated within the
recommended time-frames, which is
usually within 2 hours and no later than
72 hours after exposure.
When deciding whether to recommend
the initiation of post-exposure prophylaxis,
the clinician should assess the following
factors.
The circumstances that led to HIV
exposure
Assessment should include the
determination of whether the risk is an
isolated event, episodic event, or
habitual risk behaviour. Post-exposure
prophylaxis is recommended in
situations in which there is an isolated
exposure (sexual, needle or trauma);
however, it should not solely be
dismissed on the basis of repeated
high-risk behaviour(s). Persons who
present with repeated high-risk
behaviour(s) or for repeated courses of
post-exposure prophylaxis should be
the focus of intensified education and
prevention interventions.
Degree of transmission risk based
on type of exposure
Determining the degree of risk of HIV
transmission is an important factor in
guiding both patient and clinician in
making a decision concerning the
provision of post-exposure prophylaxis.
The health care provider should have a
frank discussion with the patient regarding
sexual activities, needle sharing and
other activities that have potential for
exposure to blood and body fluids2 .
Evaluation should also assess the
presence of other factors known to further
increase the risk of HIV transmission
such as trauma at the site of exposure,
and in cases of sexual exposure, the
presence of genital ulcers and/or other
sexually transmitted infections.