What is the recommended treatment for HIV post-exposure prophylaxis (HIV PEP)?

HIV Post-Exposure Prophylaxis (PEP) Recommendations

The recommended treatment for HIV post-exposure prophylaxis is a 28-day course of a three-drug antiretroviral regimen, with bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus tenofovir (alafenamide or disoproxil fumarate) plus emtricitabine (or lamivudine) as the preferred regimens, initiated as soon as possible and no later than 72 hours after exposure. 1, 2

Timing and Duration

• PEP must be initiated as soon as possible after exposure, ideally within hours but no later than 72 hours 1
• The complete 28-day course is essential for maximum effectiveness 2, 1
• Delayed initiation significantly decreases effectiveness 1

Recommended Regimens

For Adults and Adolescents:

• Preferred regimens:

  • Bictegravir/emtricitabine/tenofovir alafenamide (single tablet) OR
  • Dolutegravir + (tenofovir alafenamide or tenofovir disoproxil fumarate) + (emtricitabine or lamivudine) 2, 1

• Alternative regimens:

  • TDF + 3TC (or FTC) as backbone with LPV/r or ATV/r as the third drug 2
  • Where available, RAL, DRV/r, or EFV can be considered as alternative third drugs 2

For Children ≤10 years:

• Preferred backbone: ZDV + 3TC 2, 1
• Preferred third drug: LPV/r 2, 1
• Alternative backbones: ABC + 3TC or TDF + 3TC (or FTC) 2
• Alternative third drugs: ATV/r, RAL, DRV, EFV, or NVP 2

Risk Assessment and Indication

PEP is indicated when:

• Exposure occurred within the past 72 hours 2, 1
• The exposure presents a substantial risk for HIV transmission (sexual, needle-sharing, or other exposure to blood or body fluids) 2
• The source person is known to be HIV-positive without sustained viral suppression OR their viral suppression status is unknown 2

Implementation Protocol

1. Initial Assessment:

   • Perform rapid HIV test or laboratory-based antigen/antibody combination test before PEP initiation 2, 1
   • Do not delay first dose while awaiting test results 2, 1

2. Prescribing:

   • Provide the full 28-day course at the initial visit 2, 1
   • Avoid partial prescriptions ("starter packs") as evidence suggests better completion rates with full prescriptions 2

3. Monitoring:

   • Schedule follow-up at 24 hours after starting PEP 1
   • Conduct laboratory testing at 4-6 weeks and 12 weeks after exposure 1
   • Monitor for drug toxicity, especially in patients with risk factors for kidney injury 1

4. Adherence Support:

   • Provide enhanced adherence counseling for all individuals initiating PEP 2, 1
   • Discuss potential side effects and management strategies 1
   • Consider adherence tools to improve completion rates 1

Special Considerations

• Pregnancy: Avoid efavirenz (EFV) due to teratogenic effects and stavudine (d4T) + didanosine (ddI) due to risk of fatal lactic acidosis 1
• Source with known antiretroviral use: Consider the source person's history of antiretroviral medication use and viral load when selecting PEP medications to avoid potential resistance 2
• Transition to PrEP: Assess for ongoing HIV risk at completion of PEP and consider transitioning directly to PrEP without interruption for individuals with continuing risk 1

Common Pitfalls to Avoid

1. Delayed initiation: Starting PEP beyond 72 hours significantly reduces effectiveness and is not recommended 1
2. Incomplete course: Failing to complete the full 28-day regimen reduces effectiveness 1
3. Inadequate follow-up: Missing follow-up appointments for monitoring and testing 1
4. Failure to consider drug resistance: When source person's virus is known or suspected to be resistant, select drugs accordingly 1
5. Overlooking transition to PrEP: Individuals with ongoing HIV exposure risk should be transitioned directly from PEP to PrEP without interruption 1

By following these evidence-based recommendations, healthcare providers can optimize the effectiveness of HIV post-exposure prophylaxis while minimizing adverse effects and ensuring appropriate follow-up care.