Post-exposure prophylaxis for HIV: Difference between revisions
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− | == |
+ | ==Background== |
*Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual |
*Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual |
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+ | *HIV does not survive very long outside of the human body, which is why a random needle in park, for example, is very low risk |
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− | == |
+ | ==Management== |
+ | |||
+ | ===Risk Assessment=== |
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+ | |||
+ | *If the source person is available and consents to testing, this can be done to more accurately risk stratify the exposure |
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+ | *In general, prophylaxis is indicated if the estimated risk is '''greater than 0.1%''' |
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+ | |||
+ | {| class="wikitable" |
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+ | |+Risk of HIV-positive source |
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+ | !Risk |
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+ | !Examples |
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+ | |- |
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+ | | rowspan="2" |substantial |
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+ | |HIV-positive with detectable viral load (100%) |
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+ | |- |
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+ | |HIV status unknown, but from a population with high prevalence such as MSM (~23%) or PWID (~13%) |
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+ | |- |
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+ | |low but nonzero |
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+ | |HIV positive and believed to have undetectable viral load, with concomitant STI at time of exposure |
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+ | |- |
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+ | | rowspan="3" |negligible or none |
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+ | |confirmed HIV negative (0%) |
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+ | |- |
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+ | |HIV positive with confirmed viral load <40 copies/mL without known STI at time of exposure |
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+ | |- |
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+ | |HIV status unknown, in the general population (0.25%) |
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+ | |} |
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{| class="wikitable" |
{| class="wikitable" |
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+ | |+Risk of HIV transmission per act by exposure type from an HIV-positive source |
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− | !Level |
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+ | !Risk |
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!Exposure |
!Exposure |
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! align="center" |Estimated risk per act % |
! align="center" |Estimated risk per act % |
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|Blood on compromised skin |
|Blood on compromised skin |
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+ | | align="center" |— |
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+ | |- |
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+ | |Negligible |
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+ | |Found needle |
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| align="center" |— |
| align="center" |— |
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|} |
|} |
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+ | {| class="wikitable" |
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− | ==Investigations== |
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+ | |+Recommended management by source and exposure risk |
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+ | !Risk of HIV-Positive Source |
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+ | !Risk From Exposure |
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+ | !Action |
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+ | |- |
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+ | | rowspan="2" |substantial |
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+ | |low |
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+ | |PEP not required |
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+ | |- |
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+ | |moderate or high |
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+ | |initiate PEP |
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+ | |- |
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+ | | rowspan="2" |low |
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+ | |low |
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+ | |PEP not required |
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+ | |- |
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+ | |moderate or high |
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+ | |consider PEP |
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+ | |- |
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+ | | rowspan="2" |negligible or none |
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+ | |low |
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+ | |PEP not required |
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+ | |- |
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+ | |moderate or high |
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+ | |PEP not required |
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+ | |} |
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+ | ===Antiretroviral Therapy=== |
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− | *HIV testing at baseline and 12 weeks |
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− | *HAV-Ab, HBsAg/sAb/cAb at baseline |
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− | *HCV-Ab at baseline and 12 weeks |
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− | *Gonorrhea and chlamydia of urine, throat, and rectum at baseline and 12 weeks |
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− | *Sypthilis at baseline and 12 weeks |
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− | *CBC at baseline |
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− | *ALT and creatinine at baseline, repeated at 2 weeks if abnormal |
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− | *Pregnancy test at baseline |
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− | |||
− | ==Treatment== |
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*Screen for sexual assault, counsel about safe sex |
*Screen for sexual assault, counsel about safe sex |
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+ | *Screen for pregnancy and get baseline investigations (below) |
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− | *Start treatment within 72 hours |
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+ | *Start antiretroviral therapy within '''72 hours''' and continue for 28 days |
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− | *Tenofovir/emtricitabine 300/200 with raltegravir 400 BID, for 28 days |
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+ | **First-line: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[raltegravir]] 400 PO bid |
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− | **Preferred alternatives include TDF/FTC with darunavir/ritonavir or dolutegravir |
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+ | **Alternative: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[dolutegravir]] 50 mg PO daily |
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− | **Other alternatives include many |
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+ | **Alternative: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[darunavir]]/[[ritonavir]] 800 mg/100 mg PO daily |
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− | *Don't forget above screening |
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+ | *Don't forget screening for [[Hepatitis A virus|hepatitis A]], [[Hepatitis B virus|hepatitis B]], [[Hepatitis C virus|hepatitis C]], [[gonorrhea]], [[chlamydia]], and [[syphilis]] |
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+ | |||
+ | ===Investigations=== |
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+ | {| class="wikitable" |
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+ | !Investigation |
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+ | !Baseline |
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+ | !Week 12 |
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+ | !Notes |
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+ | |- |
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+ | |CBC |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | |- |
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+ | |ALT |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |repeat at 2 weeks if abnormal |
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+ | |- |
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+ | |creatinine |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |repeat at 2 weeks if abnormal |
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+ | |- |
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+ | |[[Hepatitis A virus|hepatitis A]] serology |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | |- |
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+ | |[[Hepatitis B virus|hepatitis B]] serology |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |includes HBsAb, HBsAg, and HBcAb |
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+ | |- |
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+ | |pregnancy test |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | | |
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+ | |- |
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+ | |[[HIV|HIV]] serology |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | |repeat at 6 months if hepatitis C seroconversion |
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+ | |- |
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+ | |[[hepatitis C]] serology |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |- |
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+ | |[[gonorrhea]] and [[chlamydia]] |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | |urine, throat, and rectum, depending on reported sexual activity |
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+ | |- |
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+ | |[[syphilis]] serology |
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+ | | style="text-align:center;" |X |
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+ | | style="text-align:center;" |X |
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+ | | |
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+ | |} |
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− | ==Follow- |
+ | ===Follow-Up=== |
− | *Initial visit; follow-up at 4-6 weeks; then repeat bloodwork at 4 months |
+ | *Initial visit; follow-up at 4-6 weeks; then repeat bloodwork at 12 weeks to 4 months |
*Take advantage of the opportunity to counsel patients on STIs, substance use, etc. |
*Take advantage of the opportunity to counsel patients on STIs, substance use, etc. |
||
==Further Reading== |
==Further Reading== |
||
− | * |
+ | *Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. ''CMAJ''. 2017;189(47):e1448-e1458. doi: [https://doi.org/10.1503/cmaj.170494 10.1503/cmaj.170494] |
[[Category:HIV]] |
[[Category:HIV]] |
Latest revision as of 14:50, 5 July 2022
Background
- Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual
- HIV does not survive very long outside of the human body, which is why a random needle in park, for example, is very low risk
Management
Risk Assessment
- If the source person is available and consents to testing, this can be done to more accurately risk stratify the exposure
- In general, prophylaxis is indicated if the estimated risk is greater than 0.1%
Risk | Examples |
---|---|
substantial | HIV-positive with detectable viral load (100%) |
HIV status unknown, but from a population with high prevalence such as MSM (~23%) or PWID (~13%) | |
low but nonzero | HIV positive and believed to have undetectable viral load, with concomitant STI at time of exposure |
negligible or none | confirmed HIV negative (0%) |
HIV positive with confirmed viral load <40 copies/mL without known STI at time of exposure | |
HIV status unknown, in the general population (0.25%) |
Risk | Exposure | Estimated risk per act % |
---|---|---|
Very high | Transfusion | 92.5 |
High | Anal (receptive) | 1.38 |
Needle sharing | 0.63 | |
Moderate | Anal (insertive) | 0.11 |
Vaginal (receptive) | 0.08 | |
Vaginal (insertive) | 0.04 | |
Low | Oral sex (giving) | — |
Oral sex (receiving) | — | |
Oral-anal contact | — | |
Sharing sex toys | — | |
Blood on compromised skin | — | |
Negligible | Found needle | — |
Risk of HIV-Positive Source | Risk From Exposure | Action |
---|---|---|
substantial | low | PEP not required |
moderate or high | initiate PEP | |
low | low | PEP not required |
moderate or high | consider PEP | |
negligible or none | low | PEP not required |
moderate or high | PEP not required |
Antiretroviral Therapy
- Screen for sexual assault, counsel about safe sex
- Screen for pregnancy and get baseline investigations (below)
- Start antiretroviral therapy within 72 hours and continue for 28 days
- First-line: tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg PO daily plus raltegravir 400 PO bid
- Alternative: tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg PO daily plus dolutegravir 50 mg PO daily
- Alternative: tenofovir disoproxil fumarate/emtricitabine 300 mg/200 mg PO daily plus darunavir/ritonavir 800 mg/100 mg PO daily
- Don't forget screening for hepatitis A, hepatitis B, hepatitis C, gonorrhea, chlamydia, and syphilis
Investigations
Investigation | Baseline | Week 12 | Notes |
---|---|---|---|
CBC | X | ||
ALT | X | repeat at 2 weeks if abnormal | |
creatinine | X | repeat at 2 weeks if abnormal | |
hepatitis A serology | X | ||
hepatitis B serology | X | includes HBsAb, HBsAg, and HBcAb | |
pregnancy test | X | ||
HIV serology | X | X | repeat at 6 months if hepatitis C seroconversion |
hepatitis C serology | X | X | |
gonorrhea and chlamydia | X | X | urine, throat, and rectum, depending on reported sexual activity |
syphilis serology | X | X |
Follow-Up
- Initial visit; follow-up at 4-6 weeks; then repeat bloodwork at 12 weeks to 4 months
- Take advantage of the opportunity to counsel patients on STIs, substance use, etc.
Further Reading
- Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ. 2017;189(47):e1448-e1458. doi: 10.1503/cmaj.170494