What is the recommended treatment for HIV exposure?

HIV Post-Exposure Prophylaxis (PEP) Treatment

The recommended treatment for HIV exposure is post-exposure prophylaxis (PEP) with a 28-day course of antiretroviral therapy, which should be initiated as soon as possible after exposure, ideally within hours and no later than 72 hours. 1

Timing of PEP Initiation

• PEP is most effective when started as soon as possible after exposure
• Optimal window: Within first 24 hours
• Maximum window: 72 hours after exposure
• Do not delay PEP initiation while waiting for source person's HIV test results 1

Preferred PEP Regimens for Adults

First-Line Regimen:

• Bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) 1

Alternative Regimens:

• Dolutegravir (DTG) plus (tenofovir alafenamide [TAF] OR tenofovir disoproxil fumarate [TDF]) plus (emtricitabine [FTC] OR lamivudine [3TC]) 1
• TDF/FTC plus raltegravir or dolutegravir 2
• TDF/FTC with cobicistat- or ritonavir-boosted darunavir or TDF/FTC/cobicistat/elvitegravir 2

Duration of Treatment

• All PEP regimens should be administered for 28 days 1, 2
• Complete the full course even if the source is later determined to be HIV-negative 1

Exposure Risk Assessment

1. Evaluate the nature and timing of exposure
2. Assess HIV status of the source person (if known)
3. Consider local HIV prevalence if source status unknown
4. Evaluate type of exposure (sexual, occupational, injection drug use)

Follow-up Testing and Monitoring

Initial Follow-up:

• 3-7 days after starting PEP: Assess medication tolerance
• 24 hours after starting: Monitor for side effects 1

HIV Testing Schedule:

• Baseline: Confirm HIV-negative status before starting PEP
• 4-6 weeks after exposure: Interim HIV Ag/Ab test plus diagnostic HIV NAT
• 12 weeks after exposure: Final HIV testing with laboratory-based HIV Ag/Ab combination immunoassay and diagnostic HIV NAT 1

Laboratory Monitoring:

• Baseline: Complete blood count, liver function tests, renal function
• Follow-up: Repeat tests at 2 weeks to monitor for drug toxicity 1

Managing Side Effects

• Common side effects include nausea (26.5%), malaise, and fatigue (22.8%) 1
• Consider prescribing anti-nausea medications to improve adherence
• Adherence challenges are significant (17-47% do not complete the full course) 1

Special Considerations

Pregnancy:

• PEP should not be withheld due to pregnancy
• Avoid efavirenz in pregnant women or women who might become pregnant 1

Transition to PrEP:

• For persons with anticipated ongoing HIV exposures, consider transition from PEP to PrEP after completing the 28-day PEP regimen 1

Sexual Assault Survivors:

• Should receive comprehensive care including STI testing, treatment, and support services 1

Common Pitfalls to Avoid

1. Delaying initiation: Starting PEP beyond 72 hours significantly reduces efficacy
2. Incomplete adherence: Failure to complete the full 28-day course reduces effectiveness
3. Inadequate follow-up: Missing scheduled HIV testing may delay diagnosis if PEP fails
4. Neglecting other STIs: HIV exposure often involves risk for other infections
5. Not considering PrEP: Individuals with recurrent exposures should be evaluated for PrEP after completing PEP

PEP is a critical intervention for preventing HIV infection after exposure, but its effectiveness depends on prompt initiation and complete adherence to the prescribed regimen. Healthcare providers should be prepared to rapidly assess exposure risk and initiate appropriate therapy when indicated.