What is the recommended protocol for initiating Post-Exposure Prophylaxis (PEP) treatment in a patient?

Protocol for Initiating HIV Post-Exposure Prophylaxis (PEP) Treatment

HIV PEP should be offered and initiated as early as possible, ideally within 24 hours but no later than 72 hours after exposure, in all individuals with an exposure that has potential for HIV transmission. 1

Step 1: Exposure Risk Assessment

Evaluate if the exposure warrants PEP based on:

Exposures that warrant PEP:

• Bodily fluids involved:

  • Blood, blood-stained saliva
  • Breast milk, genital secretions
  • Cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids 1

• Exposure route:

  • Mucous membrane exposure (sexual exposure, splashes to eye, nose, or oral cavity)
  • Parenteral exposures (needlestick, sharps injuries) 1

Exposures that do NOT require PEP:

• When the exposed individual is already HIV positive
• When the source is confirmed HIV negative
• Exposure to bodily fluids that don't pose significant risk (tears, non-blood-stained saliva, urine, sweat) 1

Step 2: Source Assessment

• Determine HIV status of the source whenever possible
• In settings with high HIV prevalence or when source is known to be high-risk, consider PEP without risk assessment 1
• If source status is unknown but exposure warrants PEP, initiate treatment while awaiting test results 1

Step 3: Baseline Testing of Exposed Person

• Perform rapid HIV test or laboratory-based antigen/antibody combination test
• Important: Do not delay PEP initiation while awaiting test results 1
• If clinical suspicion of acute HIV infection exists, perform HIV RNA testing 1

Step 4: PEP Regimen Selection

For Adults and Adolescents:

• Preferred backbone regimen: TDF + 3TC (or FTC) 1
• Preferred third drug: LPV/r or ATV/r 1
• Alternative third drugs: RAL, DRV/r, or EFV (avoid EFV in women of childbearing age) 1

For Children ≤10 years:

• Preferred backbone: ZDV + 3TC 1
• Alternative backbones: ABC + 3TC or TDF + 3TC (or FTC) 1
• Preferred third drug: LPV/r 1
• Alternative third drugs: ATV/r, RAL, DRV, EFV, or NVP 1

Step 5: PEP Administration

• Timing: Start as soon as possible after exposure, ideally within hours 1
• Duration: Full 28-day course 1
• Dispensing: Provide full 28-day prescription at initial visit 1
• Follow-up: Schedule first follow-up within 72 hours of exposure for reevaluation, especially if additional information about the source becomes available 1

Step 6: Adherence Support

• Provide enhanced adherence counseling for all individuals initiating PEP 1
• Discuss potential side effects and management strategies
• Emphasize importance of completing the full 28-day course

Step 7: Follow-up Testing and Monitoring

• Perform HIV antibody and antigen testing at 4-6 weeks and 12 weeks after exposure 2
• Monitor for drug toxicity, especially in patients with risk factors for kidney injury 1
• For those with ongoing risk, discuss transition to PrEP after completing PEP 2

Important Considerations

• If source is later determined to be HIV-negative, PEP can be discontinued 1
• For pregnant individuals, evaluate risk/benefit with special consideration of drug safety in pregnancy 1
• If uncertain about regimen choice, start basic regimen immediately rather than delaying PEP 1
• In case of sexual assault or high-risk sexual exposure, consider testing for other STIs 2

Common Pitfalls to Avoid

1. Delaying initiation: PEP efficacy decreases with time; start within 24 hours when possible
2. Inadequate adherence support: PEP completion rates improve with proper counseling
3. Overlooking drug interactions: Check for interactions with patient's current medications
4. Missing follow-up: Ensure proper monitoring for toxicity and seroconversion
5. Failing to address ongoing risk: Discuss risk reduction strategies and consider PrEP for those with continued exposure risk

Remember that while PEP is highly effective when initiated promptly, it is not 100% effective in preventing HIV seroconversion, and patients should be counseled accordingly 3.