What is the recommended course of action for a patient who had an unprotected sexual encounter 7 days ago?

Management of Unprotected Sexual Exposure at 7 Days Post-Encounter

For a patient who had an unprotected sexual encounter 7 days ago, nonoccupational post-exposure prophylaxis (nPEP) is no longer recommended as the 72-hour window for effective initiation has passed. 1

Assessment and Initial Management

At 7 days post-exposure, the following approach is recommended:

1. HIV Testing

   • Perform baseline HIV testing using a laboratory-based HIV antigen/antibody combination immunoassay
   • Consider HIV RNA testing if there are symptoms suggestive of acute HIV infection
   • This establishes baseline status and rules out pre-existing infection

2. Risk Assessment

   • Evaluate the nature of the exposure (anal, vaginal, oral)
   • Assess source partner's HIV status if known
   • Determine if this was an isolated incident or if ongoing risk exists

Management Options Based on Risk

Option 1: Pre-Exposure Prophylaxis (PrEP) Initiation

For patients with ongoing HIV risk:

• Initiate PrEP after confirming negative HIV status

• Preferred regimens:

  • Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) for all populations 1
  • Dolutegravir plus tenofovir alafenamide/emtricitabine (DTG + TAF/FTC) or tenofovir disoproxil fumarate/emtricitabine (DTG + TDF/FTC) 1

• Dosing options:

  • Daily PrEP: One tablet daily (recommended for all populations)
  • On-demand PrEP (2-1-1 dosing): Only for cisgender MSM - not recommended for women or transgender individuals 1

Option 2: Monitoring Without PrEP

For patients without ongoing risk:

• Schedule follow-up HIV testing at 4 weeks and 12 weeks post-exposure 1
• Provide risk reduction counseling
• Consider STI screening based on exposure type

Additional Testing Recommendations

• STI screening: Test for gonorrhea, chlamydia, and syphilis at anatomic sites of exposure
• Hepatitis B and C: Screen for both infections
• Pregnancy test: For women of childbearing potential

Follow-up Care

• If initiating PrEP, schedule follow-up within 30 days to assess adherence and tolerability 1
• Subsequent follow-up every 3 months for HIV testing and STI screening 1
• Monitor renal function with creatinine clearance testing at baseline and periodically during follow-up 1

Important Considerations

• Missed opportunity: The 72-hour window for nPEP has been exceeded, highlighting the importance of seeking care immediately after potential exposure 1, 2
• Transition to PrEP: For patients with ongoing risk, immediate initiation of PrEP is appropriate after confirming HIV-negative status 1
• Adherence support: Provide education on the importance of consistent medication use if PrEP is initiated 1

Common Pitfalls to Avoid

• Delaying care further: Even though the nPEP window has passed, prompt evaluation is still essential
• Overlooking ongoing risk: Assess for patterns of risk behavior that might warrant PrEP
• Inadequate follow-up: Ensure proper testing at recommended intervals even if the patient declines PrEP

By following this approach, you can provide appropriate care despite missing the window for nPEP, focusing on determining current HIV status and preventing future infections through PrEP if indicated.