HIV Post-Exposure Prophylaxis (PEP) Recommendations
The current recommended first-line regimen for HIV post-exposure prophylaxis (PEP) is Bictegravir/emtricitabine/tenofovir alafenamide (single tablet) or Dolutegravir + (tenofovir alafenamide or tenofovir disoproxil fumarate) + (emtricitabine or lamivudine), which should be started as soon as possible after exposure and continued for 28 days. 1
Timing and Duration
- PEP should be initiated as soon as possible after exposure - ideally within hours and no later than 72 hours
- Complete 28-day course is required for effectiveness
- Delayed initiation significantly decreases effectiveness
Recommended Regimens
First-Line Regimen
- Bictegravir/emtricitabine/tenofovir alafenamide (single tablet)
- OR
- Dolutegravir + (tenofovir alafenamide or tenofovir disoproxil fumarate) + (emtricitabine or lamivudine)
Alternative Regimens
- Lamivudine (3TC) + Stavudine (d4T)
- Didanosine (ddI) + Stavudine (d4T)
- Zidovudine (ZDV) + Lamivudine (3TC) - available as Combivir
Special Populations
Pregnant Individuals
- Avoid efavirenz (EFV) due to teratogenic effects
- Avoid stavudine (d4T) + didanosine (ddI) combination due to risk of fatal lactic acidosis
- Avoid indinavir (IDV) near delivery due to risk of hyperbilirubinemia in newborns
Children ≤10 years
- Backbone regimen: Zidovudine (ZDV) + lamivudine (3TC)
- Preferred third drug: lopinavir/ritonavir (LPV/r)
Evaluation and Monitoring
Initial Assessment
- Assess risk of infection using available information
- Test known sources for HIV antibody (consider rapid testing)
- For unknown sources, assess risk of exposure to HIV
- Baseline testing for exposed person: HIV antibody, hepatitis B and C serology, creatinine, liver enzymes
Follow-up
- 24-hour follow-up with provider
- Laboratory testing at 4-6 weeks and 12 weeks after exposure
- HIV antibody testing at baseline, 6 weeks, 3 months, and 6 months post-exposure
- Monitor for drug toxicity for at least 2 weeks
Adherence Support
- Provide full 28-day prescription at initial visit
- Offer enhanced adherence counseling
- Discuss potential side effects and management strategies
- Consider adherence tools
Transition to PrEP
- Assess for ongoing HIV risk at completion of PEP
- Transition directly from PEP to PrEP without interruption for individuals with continuing risk
Common Pitfalls to Avoid
- Delaying initiation beyond 72 hours (ineffective)
- Prescribing incomplete courses (reduced effectiveness)
- Failing to consider drug resistance in source patients
- Overlooking transition to PrEP for those with ongoing risk
- Not providing adequate adherence support
The effectiveness of PEP is supported by animal studies, occupational exposure data, and prevention of mother-to-child transmission evidence, highlighting the importance of prompt initiation and complete adherence to the recommended regimen 1, 2. While older guidelines recommended two-drug regimens in certain circumstances 3, current evidence supports the use of three-drug regimens for all occupational exposures to HIV 2.
AI-generated content review: This response provides specific recommendations for HIV PEP based on the most recent guidelines, including specific drug regimens, timing, duration, monitoring requirements, and considerations for special populations.