What is the recommended treatment after sexual exposure to HIV?

HIV Post-Exposure Prophylaxis After Sexual Exposure

For persons seeking care within 72 hours after sexual exposure to HIV from a known HIV-infected source, a 28-day course of highly active antiretroviral therapy (HAART) is strongly recommended to prevent HIV infection. 1

Evaluation and Initiation of Treatment

Timing of PEP

• PEP must be initiated as soon as possible after exposure, ideally within 24 hours, but no later than 72 hours 2
• Effectiveness decreases with delay - every hour counts
• Do not delay first dose while waiting for laboratory test results 2

Risk Assessment

1. Determine exposure type and risk level:

   • Highest risk: Receptive anal intercourse
   • Moderate risk: Insertive anal intercourse, receptive vaginal intercourse
   • Lower risk: Insertive vaginal intercourse, oral sex
   • Risk increases with presence of blood, genital ulcers, or STIs 1

2. Determine HIV status of source:

   • Known HIV-positive source: PEP strongly recommended
   • Unknown HIV status but from high-risk group (MSM, PWID): Consider PEP on case-by-case basis
   • Unknown status from low-risk population: PEP generally not recommended 1

3. Baseline testing of exposed person:

   • Rapid HIV test before starting PEP (don't delay PEP for results)
   • Pregnancy test for women of childbearing age
   • STI screening
   • Liver and kidney function tests 1, 2

Recommended PEP Regimen

Preferred Regimens

• Current preferred regimens (2025): 2

  • Bictegravir/emtricitabine/tenofovir alafenamide OR
  • Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine)

• Alternative regimens (if preferred not available): 1

  • Efavirenz and lamivudine/emtricitabine with zidovudine/tenofovir OR
  • Lopinavir/ritonavir and zidovudine with lamivudine/emtricitabine

• Duration: Full 28-day course required 1, 2

Follow-up Care

Monitoring

• Initial follow-up at 24 hours (in person or remote) 2
• Clinical follow-up at 4-6 weeks and 12 weeks after exposure 2
• HIV testing at 4-6 weeks and 3 months post-exposure
• Monitor for medication side effects (nausea, fatigue, headache)
• Assess medication adherence at each visit 1

Adherence Support

• Counsel on importance of completing full 28-day regimen
• Prescribe antiemetics or antimotility agents if needed to manage side effects
• Provide adherence counseling and support 1

Special Considerations

Sexual Assault Victims

• Initiate PEP as soon as possible
• Additional prophylaxis for other STIs and pregnancy prevention
• Consider psychological support and follow-up
• Be aware that adherence may be particularly challenging in this population (only 27% took ≥90% of medications in one study) 3

Transition to PrEP

• Assess need for ongoing HIV prevention
• For persons with continued risk, transition directly from PEP to PrEP
• Create an nPEP-to-PrEP transition plan for those who accept PrEP 2

Common Pitfalls to Avoid

1. Delayed initiation: Effectiveness decreases significantly after 72 hours
2. Poor adherence: Only 69% of patients attend follow-up and many don't complete the full course 4
3. Failure to address other STIs: Concurrent STIs were found in 8.3% of PEP recipients in one study 4
4. Missing follow-up testing: Only 35% of patients attended for 3-month follow-up serology in one study 4
5. Prescribing PEP for negligible risk exposures: Not recommended for exposures with minimal risk or when >72 hours have passed 1

Implementation Challenges

• Poor adherence to both medications and follow-up visits is a significant problem 3
• Side effects occur in approximately 48% of patients, commonly including abdominal pain, nausea, and vomiting 3
• Public awareness about PEP availability remains limited 5

Remember that PEP is an emergency intervention and should be part of a comprehensive HIV prevention strategy. The most effective method for preventing HIV infection remains avoiding exposure in the first place 1.