New+Guidelines+for+Postexposure+prophylaxis

New guidelines have come out for Post Exposure Prophylaxis (PEP) for HIV ( http://www.nccc.ucsf.edu/docs/2013_PEP_GLs.pdf) and they have a couple of changes, most notably that medications should be administered "as soon as possible" after the exposure and that **a 3-drug regimen should be used (Truvada qD+ Raltegravir BID)** instead of the 2-drug treatment (Truvada, which is Tenofovir + Emtricitabine).
 * First doses of these pills are now stocked at all our health centers as well as the ED** . Health Center providers are often the first point of contact for an employee with a blood or body fluid exposure and you should be encouraged to have the patient **"swallow first, ask questions later."** A single dose of PEP is extremely non-toxic and at least in theory the effectiveness depends in large part as to how soon it is given after exposure. Raltegravir is dosed bid so after taking the first dose you and the employee have 12 hours to assess level of risk to decide whether to continue further PEP dosing.

A few PEP reminders:

Use the Order Sets for "Employee Exposure" on Epic when ordering labs. A goal is to have the Source patient tested within 1 hr of exposure when possible, and hopefully have this guide the need for further doses of PEP. If you have clinical questions, call the National PEPline at 888-448-4911.

For Truvada the main side effects are nephrotoxicity (rare with patients with baseline normal kidneys), rash (rare), and post-treatment exacerbation of chronic active Hep B. Raltegravir's side effects are insomnia, nausea, fatigue, HA, and skin hypersensitivity rxn, all extremely rare.

Per Kathy, if it is an employee with CCHP then they can get the Rx for the full 4 weeks of PEP at Walgreens without a co-pay; if they have Kaiser then also not a problem. Per deum employees are less straightforward. Without coverage, Truvada alone costs $1500 for 28 days.

Leave Kathy Ferris a message at 5079 so she knows to followup with the patient and ensure the appointment is within 72 hours of being seen.

Chris Farnitano, MD (12-2014)

Ambulatory Care Medical Director

Contra Costa Health Services

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