Post-Exposure Prophylaxis (PEP)

Indications

Post-exposure prophylaxis (PEP) is the use of antiretroviral medication to prevent HIV infection in an HIV-negative person who has had a specific high-risk exposure to HIV. PEP initiation should be considered in people whose vagina, rectum, eye, mouth or other mucuous membrane, non-intact skin, or perforated skin (eg, needle stick) come into contact with potentially contaminated body fluids from an HIV-infected source, as long as exposure has occurred within a 72-hour window. (If the source is of unknown HIV status, a case-by-case determination may be made.)

Contraindications

• PEP is only indicated for potentially exposed people without HIV infection.
• PEP is unlikely to be effective in people who have been exposed more than 72 hours before seeking medical assistance.
• PEP should be provided only for infrequent exposures. People who engage in behaviors that result in frequent, recurrent exposures to HIV should be considered for intensive sexual or injection risk-reduction interventions and pre-exposure prophylaxis (PrEP) with daily oral doses of combination TDF+FTC (Truvada®). However if the most recent recurring exposure is within the 72-hour window prior to an evaluation, PEP may be indicated with transition of the patient to PrEP after completion of 28 days of PEP medication.

Recommended treatment

All persons offered PEP should be prescribed a 28-day course of a 3-drug antiretroviral regimen. Since adherence is critical for PEP efficacy, it is preferable to select regimens that minimize side effects, number of doses per day and the number of pills per dose.

The preferred PEP regimen for otherwise healthy adults and adolescents is tenofovir disoproxil fumarate (TDF) (300 mg) + emtricitibine (FTC) 200 mg) once daily PLUS raltegravir (RAL) (400 mg) twice daily or dolutegravir (DTG) (50 mg) once daily).

Guidelines recommend the following baseline screening before initiating PEP:

• HIV rapid test at baseline. If baseline rapid test indicates existing HIV infection, PEP should not be started. However, if rapid HIV baseline test is not available, there should be no delay in starting PEP. Oral HIV tests are not recommended for use among persons being evaluated for PEP.
• Pregnancy test (if a woman is of reproductive age, not using highly effective contraception, eg IUDs or other long-active reversible contraceptives (LARCs), oral contraceptives, or properly used condoms, and with vaginal exposure to semen).
• Serum liver enzymes
• BUN/creatinine
• STI screening
  • Persons being evaluated for PEP because of a sexual encounter should have STI-specific nucleic acid amplification (NAAT testing) for chlamydia and gonorrhea, and a blood test for syphilis
• Hepatitis B testing, including hepatitis B surface antigen, surface antibody, and core antibody
• Hepatitis C (HCV) antibody

Note: The first dose of PEP should always be expedited; testing can wait until after PEP has been initiated.

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