What is the recommended treatment for someone exposed to Human Immunodeficiency Virus (HIV)?

HIV Post-Exposure Prophylaxis (PEP) Recommendations

HIV post-exposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours but no later than 72 hours after exposure, and continued for 28 days for individuals with substantial risk of HIV transmission. 1, 2

Exposure Assessment and Eligibility

Exposures that warrant PEP:

• Bodily fluids with risk of transmission:

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

• Types of exposure:

  • 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 person 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

Timing of PEP

• Initiate PEP as soon as possible - efficacy decreases with time
• Optimal window: Within first 24 hours 2
• Maximum window: Within 72 hours of exposure 1, 2
• Do not delay initiation while waiting for HIV test results of the source person 1

Recommended PEP Regimens

Preferred regimens for adults and adolescents:

1. First choice (2025 recommendation):

   • Bictegravir/emtricitabine/tenofovir alafenamide OR
   • Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 3

2. Alternative regimen:

   • Tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) or emtricitabine (FTC) as backbone
   • Plus a third drug such as lopinavir/ritonavir 1

Duration:

• Complete 28-day course regardless of exposure severity 2

Baseline and Follow-up Testing

Initial assessment:

• Baseline HIV testing to confirm HIV-negative status 2
• Assessment of other potential infections (HBV, HCV, STIs)
• Pregnancy testing for women of reproductive age 1

Follow-up:

• Initial follow-up at 24-72 hours (in person or remote) to assess medication tolerance 2, 3
• HIV testing at 4-6 weeks, 3 months, and 6 months post-exposure 2
• Testing for other STIs as appropriate 2

Improving Adherence

• Supportive medications (anti-nausea, anti-diarrheal) to manage side effects 2
• Common side effects include nausea (26.5%) and fatigue (22.8%) 2
• Studies show 17-47% of individuals don't complete the full course due to medication intolerance 2
• Consider prescribing medications with fewer doses and pills per dose 2

Special Considerations

Source person with unknown HIV status:

• Evaluate risk on a case-by-case basis
• Consider local HIV prevalence and risk factors of source 1
• In high-prevalence settings or when source is at high risk for HIV, PEP may be warranted 1

Pregnancy:

• PEP should not be withheld due to pregnancy
• Avoid efavirenz in pregnant women or women who might become pregnant 2

Transition to PrEP

• After completing PEP, evaluate individuals for pre-exposure prophylaxis (PrEP) if they have ongoing HIV risk factors 2, 3
• Create an nPEP-to-PrEP transition plan for persons with continuing exposure risk 3

Implementation Considerations

• Self-start PEP has shown promise in reducing time to first dose by 21+ hours (7.3 vs 28.5 hours), significantly improving efficacy 4
• Emergency departments should have standardized procedures to avoid delays in PEP initiation 5

Remember that the effectiveness of PEP correlates strongly with speed of uptake following exposure, making immediate initiation crucial for preventing HIV infection.