post-exposure prophylaxis (PEP) following HIV exposure

Last reviewed 01/2018

Seek expert advice and consult local guidance.

Some summary points relating post-exposure prophylaxis for HIV exposure are provided below (1):

  • post-exposure prophylaxis (PEP) should be recommended to health care workers if they have had a significant occupational exposure to blood or another high-risk body fluid from a patient or other source either known to be HIV infected, or considered to be at high risk of HIV infection, but where the result of an HIV test has not or cannot be obtained, for whatever reason
    • HIV post-exposure prophylaxis was significant - that is, with the potential to transmit HIV. There are three types of exposure in health care settings associated with significant risk. These are:
      • (i) percutaneous injury (from needles, instruments, bone fragments, significant bites which break the skin etc);
      • (ii) exposure of broken skin (abrasions, cuts, eczema etc); and
      • (iii) exposure of mucous membranes including the eye
    • body fluids and materials which may pose a risk of HIV transmission if significant occupational exposure occurs
      • amniotic fluid
      • blood
      • cerebrospinal fluid
      • exudative or other tissue fluid from burns or skin lesions
      • human breast milk
      • pericardial fluid
      • peritoneal fluid
      • pleural fluid
      • saliva in association with dentistry (likely to be contaminated with blood, even when not obviously so)
      • semen
      • synovial fluid
      • unfixed human tissues and organs
      • vaginal secretions
      • any other body fluid if visibly bloodstained
  • PEP should not be offered after exposure through any route with low-risk materials (e.g. urine, vomit, saliva, faeces) unless they are visibly bloodstained (e.g. saliva in association with dentistry)
    • also, PEP should not be offered where testing has shown that the source is HIV negative, or if risk assessment has concluded that HIV infection of the source is highly unlikely. Exceptionally, PEP may be indicated following a negative test if there is reason to suspect the source may be seroconverting (i.e. in the window period)
  • relative risk of transmission may be increased considerably if the source patient has a high plasma viral load (e.g. at the time of seroconversion or in the later stages of HIV disease)
    • infectivity of all body fluids is likely to be reduced where plasma viral load is undetectable
  • drug regimen for post-exposure HIV prophylaxis
    • antiretroviral agents from three classes of drug are currently licensed for first-line treatment of HIV infection, namely:
      • nucleoside/nucleotide analogue reverse transcriptase inhibitors (NRTIs);
      • non-nucleoside reverse transcriptase inhibitors (NNRTIs); and
      • protease inhibitors (PIs)
    • zidovudine (an NRTI) is the only drug to date which has been studied and for which there is evidence of a reduction in risk of HIV transmission following occupational exposure
      • however, as no antiretroviral drug has been licensed for PEP, they can only be prescribed for PEP on an 'off-label' basis
    • a suggested starter regimen (1):
      • after due consideration of storage/stability issues, side effect profiles, drug interactions, drug resistance and regimen simplicity (i.e. reduced pill burden and food restrictions), the following regimen is now recommended for PEP starter packs:
        • one Truvada tablet (245mg tenofovir and 200mg emtricitabine (FTC)) once a day
        • plus Two Kaletra film-coated tablets (200mg lopinavir and 50mg ritonavir) twice a day

Notes:

  • possible side effects:
    • all of the antiretroviral agents have been associated with side effects. Many of these can be managed symptomatically. Side effects of the NRTIs (e.g. tenofovir and emtricitabine) include gastrointestinal (e.g. nausea, diarrhoea) as well as dizziness and headache. In clinical trials of Kaletra, the most commonly reported side effect was diarrhoea, followed by other gastrointestinal disturbances, asthenia, headache and skin rash
  • treatment should be initiated as soon as possible ideally within hours and certainly within 48-72 hours of exposure for it to be effective. It is not generally recommended beyond 72 hours post exposure. PEP is continued for at least 28 days (2).

Follow up of all occupationally exposed healthcare workers should be undertaken and should include: counselling, post-exposure testing and medical evaluation whether or not they have received PEP (2).

  • patients should also be advised about seeking medical advice on any acute illness which may occur during this period. e.g. - rash, myalgia, fatigue, malaise or lymphadenopathy which may be due to seroconversion illness or may be caused by side effects of antiretroviral medication (2)
  • according to EAGA recommendations the minimum follow up time should be at least 12 weeks after the HIV exposure event or, if PEP was taken, for at least 12 weeks from when PEP was stopped
  • longer follow-up with additional testing may be necessary for complex cases (2)

Reference:

Related pages:

HIV

needlestick injury (risks of HIV infection)