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PEP Protocol

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Because PEP is a consultation service, attendings who are supervising residents or fellows cannot bill for PEP visits under the Primary Care Exemption rule. When PEP patients are seen by residents or fellows, supervising attendings have 2 options: (1) they can forgo billing a professional fee for that visit OR (2) suspend the Primary Care Exemption rule for that ENTIRE session – in this case, the attending must see every patient with all fellows/residents in order to bill for PEP as well as other patients.

    1. HMC EMPLOYEES – Occupational Exposures
    2. NON-HMC EMPLOYEES – Occupational Exposures
    3. NON-OCCUPATIONAL EXPOSURES - Sexual Exposures
    4. NON-OCCUPATIONAL EXPOSURES – Needle Exposures
    5. Guidelines after Sexual Assault

I. HMC EMPLOYEES – Occupational Exposures


• For HMC employees, the exposed patient first reports to the ER or the employee health department (EHD). At first appointment (either in the ER or EHD) the exposed and source patients should be tested for HBV, HCV, and HIV. If the exposed patient is to be started on antiretrovirals, a CBC, comprehensive metabolic panel, and pregnancy test (if female) should be drawn. The Hepatitis B PEP protocol is initiated at first appointment. For HIV, the ER or EHD gives the patient 3 days of antiretrovirals and information to follow-up with Madison Clinic.

• When seeing the patient at Madison Clinic one should review the laboratory tests, the choice of antiretrovirals, PEP for HBV, and monitor the patient for drug toxicities during his/her 28 days of therapy. Laboratory results not available on Mindscape are often available through the employee health nurse at 744-3081. (For details on the CDC recommendations for PEP, please see sections on management of occupational exposure on this website.)

• For PEP patients, the paperwork provided should include a data form, a billing sheet, and a form with the protocol for lab monitoring for toxicity and possible seroconversion. Prescriptions for antiretrovirals should be written for a 1 week supply with 3 refills since many patients are intolerant of the medications and must discontinue them. The patient should be seen at 1 week to assess tolerance and at the end of PEP for interview and referral back to EHD.

• Follow-up serologies for Hepatitis B and C and HIV are drawn at 6 weeks, 12 weeks, and 24 weeks as well as repeat HBV vaccination should be managed through the EHD. If the source is known to HBV and/or HCV negative, the follow-up serologies for these should be deferred.

• For patients with a percutaneous exposure from an HCV-infected source or a mucous membrane exposure from a HIV/HCV-coinfected source (or a high risk source), a HCV RNA PCR and ALT should be drawn at 6 weeks (also managed through the EHD).

• Occasionally the source patient is a Madison Clinic patient. To access his patient record to review HIV treatment history and resistance patterns, one must attempt to get consent from the source patient. If after an hour of trying to contact the source patient one is unable to get consent, and you believe review of the record is vital for good patient care to the exposed patient, then it is allowable to access the source patient’s chart to provide appropriate care to the exposed patient. If the source patient refuses consent call Edith Allen from the Department of Public Health at 744-4377 for assistance.

• Further questions regarding HIV PEP should be directed to Bob Harrington or the attending of the day.

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II. NON-HMC EMPLOYEES – Occupational Exposures

• Non-HMC employees that sustained a non-occupational exposure to HIV are either seen first in the emergency room or at Madison Clinic. At this first visit (either in the ER or at Madison) the exposed and source patients (if available) should be tested for HBV, HCV, and HIV. If the exposed patient is to be started on antiretrovirals a CBC, comprehensive metabolic panel, and pregnancy test (if female) should be drawn. The Hepatitis B PEP protocol is initiated at first appointment. If the patient is first seen in the emergency room, the ER gives the patient 3 days of antiretrovirals and information to follow-up with Madison Clinic.

• When seeing the patient at Madison Clinic one should review the laboratory tests, the choice of antiretrovirals, PEP for HBV, and monitor the patient for drug toxicities during his/her 28 days of therapy. (For details on the CDC recommendations for PEP for occupational exposures, please see sections on management of occupational exposures on this website.)

• For PEP patients, the paperwork provided should include a data form, a billing sheet, and a form with the protocol for lab monitoring for toxicity and possible seroconversion. Prescriptions for antiretrovirals should be written for a 1 week supply with 3 refills since many patients are intolerant of the medications and must discontinue them. The patient should be seen at 1 week to assess tolerance and at the end of PEP for an interview.

• Follow-up serologies for Hepatitis B and C and HIV at 6 weeks, 12 weeks, and 24 weeks, and repeat HBV vaccination are done at Madison Clinic. If the source is known to HBV and/or HCV negative, the follow-up serologies for these should be deferred.

• For patients with a percutaneous exposure from an HCV-infected source or a mucous membrane exposure from a HIV/HCV-coinfected source (or high risk source), a HCV RNA PCR and ALT should be drawn at 6 weeks.

• Occasionally the source patient is a Madison Clinic patient. To access his patient record to review HIV treatment history and resistance patterns, one must attempt to get consent from the source patient. If after an hour of trying to contact the source patient one is unable to get consent, and you believe review of the record is vital for good patient care to the exposed patient, then it is allowable to access the source patient’s chart to provide appropriate care to the exposed patient. If the source patient refuses consent call Edith Allen from the Department of Public Health at 744-4377 for assistance.

• Further questions regarding HIV PEP should be directed to Bob Harrington or the attending of the day.

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III. NON-OCCUPATIONAL EXPOSURES - Sexual Exposures

• Some patients with a sexual exposure to HIV will first seek care through the emergency room while some will seek care first at Madison Clinic. Whether the first visit is in the ER or at Madison Clinic, at the first visit the exposed and source patients (if available) should be tested for HBV, HCV and HIV. The exposed patient should also be tested for syphilis, gonorrhea and chlamydia. If the exposed patient is to be started on antiretrovirals a CBC, comprehensive metabolic panel, and pregnancy test (if female) should be drawn. Consideration should be given to emergency contraception. The Hepatitis B protocol is initiated at first appointment.

• If antiretrovirals are initiated the patient should be monitored for toxicities during his/her 28 days of therapy. (For details on the CDC recommendations for PEP for non-occupational exposure see guidelines for non-occupational exposures on this website.)

• For PEP patients, the paperwork provided should include a data form, yellow billing sheet, and a form with the protocol for lab monitoring for toxicity and possible seroconversion. Prescriptions for antiretrovirals should be written for a 1 week supply with 3 refills since many patients are intolerant of the medications and must discontinue them. If patient requires Patient Assistance for their medication, medications must be dispensed as a 30 day quantity. The patient should be seen at 1 week to assess tolerance and at the end of PEP for an interview.

• Follow-up serologies for HIV are drawn at 6 weeks, 12 weeks, and 24 weeks through Madison Clinic.

• Occasionally the source patient is a Madison Clinic patient. To access his patient record to review HIV treatment history and resistance patterns, one must attempt to get consent. If after an hour of trying to contact the source patient one is unable to get consent, and you believe review of the record is vital for good patient care to the exposed patient, then it is allowable to access the source patient’s chart to provide appropriate care to the exposed patient. If the source patient refuses consent call Edith Allen from the Department of Public Health at 744-4377 for assistance.

• Patients who present with sexual assault should be directed to the Harborview Sexual Assault Center. They can help coordinate counseling, education and follow-up. NOTE: Unlike the ED, they cannot provide antiretrovirals.

• Further questions regarding HIV PEP should be directed to Bob Harrington or the attending of the day.

• Clinical practice. Postexposure prophylaxis for HIV infection
[N Engl J Med. 2009 Oct 29;361(18):1768-75].

• CDC 2005 Guidelines on Non-occupational Exposure to HIV:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm

IV. NON-OCCUPATIONAL EXPOSURES – Needle Exposures

• Some patients with a needle exposures to HIV will first seek care through the emergency room while some will seek care first at Madison Clinic. Whether the first visit is in the ER or at Madison Clinic, at the first visit the exposed and source patients (if available) should be tested for HBV, HCV and HIV. If the exposed patient is to be started on antiretrovirals a CBC, comprehensive metabolic panel, and pregnancy test (if female) should be drawn. The Hepatitis B protocol is initiated at first appointment.

• If antiretrovirals are initiated the patient should be monitored for toxicities during his/her 28 days of therapy. (For details on the CDC recommendations for PEP for non-occupational exposure see guidelines for non-occupational exposures on this website.)

• For PEP patients, the paperwork provided should include a data form, a billing sheet, and a form with the protocol for lab monitoring for toxicity and possible seroconversion. Prescriptions for antiretrovirals should be written for a 1 week supply with 3 refills since many patients are intolerant of the medications and must discontinue them. The patient should be seen at 1 week to assess tolerance and at the end of PEP for an interview.

• Follow-up serologies for HIV and HCV are drawn at 6 weeks, 12 weeks, and 24 weeks through Madison Clinic. If the source is known HCV negative, follow-up HCV serologies should be deferred.

• For patients with a percutaneous exposure from an HCV-infected source or a mucous membrane exposure from a HIV/HCV-coinfected source (or high-risk source), a HCV RNA PCR and ALT should be drawn at 6 weeks.

• Occasionally, the source patient is a Madison Clinic patient. To access his patient record to review HIV treatment history and resistance patterns, one must attempt to get consent. If after an hour of trying to contact the source patient one is unable to get consent, and you believe review of the record is vital for good patient care to the exposed patient, then it is allowable to access the source patient’s chart to provide appropriate care to the exposed patient. If the source patient refuses consent call Edith Allen from the Department of Public Health at 744-4377 for assistance.

• Further questions regarding HIV PEP should be directed to Bob Harrington or the attending of the day.

 

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