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Background:  Standards of practice to prevent HIV infection in health care workers exposed to an HIV-infected source patient  have been established by the U.S. Public Health Service, yet some exposures require expert interpretation. The National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline) at-888-448-4911 provides expert consultative services for clinicians managing occupational exposures. Consultations to the PEPline were  reviewed for all exposures involving an HIV-positive source patient.   

Methods: The risk and type of exposure, type of caller, professional exposed, PEP regimen started prior to PEPline consultation, source patient stage of HIV disease, viral load, CD4 count, antiretroviral regimen, and PEPline treatment recommendations were reviewed from April 1, 2002 to March 31, 2003. Sommers’ test was used to test for significant associations among categorical variables.

Results:  During this period, the PEPline received 1003 calls concerning a known HIV⁺ source patient.  Of these, viral load, CD4 count, or both were available in 263 (26.2%) of unduplicated exposures.  Nurses (28.9%), physicians (20.5%), medical/laboratory assistants (14.5%), and dentists/dental assistants (6.4%) comprised the majority of exposed health care workers. Percutaneous exposures (62.7%) were more frequent than mucocutaneous (35.3%).  Of the 127 (48.3%) exposed health care workers receiving PEP at the time of the call, mean time to starting PEP was 5.0 hours (range 1.0 to 48 hours, SD 8.41).  Source patient VL ranged from undetectable (34.9% of exposures) to >100,000. PEPline consultation recommended changing the previously initiated regimen in 44.2% (n = 56), continuing the regimen in 51.9% (n = 66), and discontinuing in 3.9% (n = 5) of exposures.  An inverse correlation between number of antiretroviral agents (ARV) used and source patient viral load was found (p <0.001).  Three or more ARV were suggested in 46.8% of exposures (n = 123), 2 in 33.1% (n = 87), none in 3.8% (n = 10), and not applicable in 16.4% (n = 43).  Of those source patient with undetectable viral load receiving PEP, PEPline recommended ARV similar to or same as the source patient in 40.2% (n = 37) of exposures. Resistance testing of the source patient was available in 4.6% (n = 12) of exposures.

Conclusions: PEPline recommended changing or discontinuing regimens in half of all cases. Recommendations to treat with PEP are determined by the severity of exposure,  transmissibility of source patient virus, and possibility of viral resistance. Complex decisions about PEP for exposures to an HIV-infected source patient may benefit from expert consultation.

Keywords: Postexposure prophylaxis; HIV+ source patient; occupational exposure