From the Guidelines
Post-exposure prophylaxis (PEP) for HIV should be prescribed as a 28-day course of antiretroviral medications, started as soon as possible after potential exposure, ideally within 72 hours, with the standard regimen consisting of tenofovir disoproxil fumarate (TDF) 300mg plus emtricitabine (FTC) 200mg once daily, combined with either raltegravir 400mg twice daily or dolutegravir 50mg once daily 1. The most recent and highest quality study recommends that PEP should be initiated without waiting for confirmation of HIV serostatus of the source patient or results of HIV RNA or resistance testing 1.
Key Considerations
- Before starting PEP, baseline HIV testing should be performed, along with tests for hepatitis B, hepatitis C, and kidney and liver function.
- Follow-up testing is recommended at 4-6 weeks and 3 months after exposure.
- Side effects like nausea, fatigue, and headache are common but usually manageable.
- PEP works by preventing HIV from establishing infection in the body by inhibiting viral replication at multiple stages, but it is not 100% effective, making timely initiation crucial.
Regimen Adjustments
- For occupational exposures or in cases where the source person is known to have drug-resistant HIV, the regimen may be adjusted based on resistance patterns 1.
- Alternative regimens, such as TDF/emtricitabine with cobicistat- or ritonavir-boosted darunavir or TDF/emtricitabine/cobicistat/elvitegravir, may be considered 1.
Adherence Support
- Ongoing discussions about adherence are recommended, especially in the absence of proven PrEP adherence interventions 1.
- Enhanced adherence counseling is suggested for all individuals initiating HIV PEP 1.
From the Research
Post-Exposure Prophylaxis (PEP) Prescription
- PEP is prescribed as a 28-day course of antiretroviral therapy (ART) to reduce the risk of HIV infection after exposure 2, 3.
- The treatment should be initiated within 36-72 hours of exposure to HIV 2.
- Various antiretroviral combinations can be used for PEP, including tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC)/rilpivirine (RPV) 4, elvitegravir/cobicistat/TDF/FTC 5, and TDF/FTC with raltegravir or zidovudine/lamivudine with a protease inhibitor 5.
PEP Regimens and Completion Rates
- A single-tablet regimen of TDF/FTC/RPV has been shown to be well-tolerated and effective for PEP, with a completion rate of 86.1% 4.
- The fixed-dose combination of elvitegravir/cobicistat/TDF/FTC has also been found to be safe and well-tolerated, with a completion rate of 71% 5.
- Historical controls using TDF/FTC and raltegravir or AZT/3TC plus a protease inhibitor had lower completion rates of 57% and 39%, respectively 5.
Side Effects and Tolerability
- Common side effects reported by PEP users include abdominal discomfort or pain, gas or bloating, diarrhea, fatigue, nausea or vomiting, headache, and dizziness or lightheadedness 5, 4.
- Most symptoms are mild, limited, and do not result in medication discontinuation 5.
- No serious adverse events or hepatic or renal toxicity have been reported with the use of TDF/FTC/RPV for PEP 4.