From the Guidelines
Post-exposure prophylaxis (PEP) for HIV should be initiated as soon as possible after exposure, ideally within 72 hours, with a 28-day course of antiretroviral therapy (ART) to maximize the benefit of the intervention. The preferred regimen is tenofovir disoproxil fumarate (TDF) 300 mg plus emtricitabine (FTC) 200 mg once daily, combined with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily, as recommended by the World Health Organization guidelines on postexposure prophylaxis for HIV 1.
Some key points to consider when administering PEP include:
- Prompt initiation of PEP, with the goal of starting treatment within 72 hours of exposure
- Completion of the full 28-day course of ART to maximize the benefit of the intervention
- Baseline HIV testing should be performed before starting PEP, with follow-up testing at 4-6 weeks and 3 months
- Side effects may include nausea, fatigue, and headache, which can be managed symptomatically
- PEP works by preventing viral replication during the initial infection phase, before HIV establishes permanent infection in the body
It's also important to note that the World Health Organization guidelines recommend enhanced adherence counseling for all individuals initiating HIV PEP, as well as monitoring for uncommon side effects 1. Additionally, the guidelines suggest that dispensing a full 28-day course of ARVs for PEP is preferred over partial prescriptions or "starter packs," as this has been shown to improve acceptance and completion rates 1.
In terms of specific dosing, the guidelines recommend the following:
- TDF 300 mg plus FTC 200 mg once daily, combined with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily
- Alternative regimens include TDF/FTC plus darunavir 800 mg with ritonavir 100 mg once daily
- For children, weight-based dosing is required
Overall, the goal of PEP is to prevent HIV infection after exposure, and prompt initiation of treatment with a 28-day course of ART is critical to achieving this goal.
From the Research
Post Exposure Prophylaxis of HIV Dose
- The recommended length of post-exposure prophylaxis (PEP) course is 28 days 2.
- The initial PEP dose should not be delayed due to pending results of any laboratory-based testing, and should be provided as soon as possible, ideally within 24 hours, but no later than 72 hours after exposure 2.
- The preferred regimens for most adults and adolescents are now bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine), however the regimen can be tailored to the clinical circumstances 2.
- Other regimens such as raltegravir, tenofovir DF, and emtricitabine have been evaluated for PEP and found to be safe, tolerable, and effective 3, 4.
- Integrase strand transfer inhibitors (INSTIs) combined with a tenofovir and lamivudine or emtricitabine backbone have been established as safe and tolerable PEP regimens 5.
- Fixed-dose combination bictegravir, emtricitabine, and tenofovir alafenamide has been found to be non-inferior to dolutegravir-containing regimens for initial treatment of HIV-1 infection 6.
Side Effects and Adherence
- Common side effects of PEP regimens include nausea or vomiting, diarrhea, headache, fatigue, abdominal symptoms, and myalgias or arthralgias, but are often mild and self-limited 3, 4.
- Adherence to PEP regimens can be high, with completion rates ranging from 89% to 92% 4.
- Regimens such as raltegravir, tenofovir DF, and emtricitabine may avoid potential drug-drug interactions and have high levels of adherence 4.
Testing and Follow-up
- A rapid HIV test or laboratory-based antigen/antibody combination HIV test is recommended before PEP initiation 2.
- Medical follow-up for persons prescribed PEP should be tailored to the clinical situation, with recommended follow-up including a visit at 24 hours and clinical follow-up 4-6 weeks and 12 weeks after exposure for laboratory testing 2.