What treatment should be ordered for a patient whose condom broke and the partner's HIV status is unknown?

Management of Potential HIV Exposure After Condom Breakage

For a patient whose condom broke with a partner of unknown HIV status, post-exposure prophylaxis (PEP) should be evaluated on a case-by-case basis, considering the risk factors and timing of exposure, with treatment initiated within 72 hours if deemed necessary. 1

Initial Assessment

• Determine timing of exposure - PEP is only recommended if the patient presents within 72 hours of the potential exposure 1
• Perform baseline HIV testing on the potentially exposed person, ideally with a rapid test kit 1
• Assess the HIV status of the source partner if possible 1
• Evaluate the specific type of sexual exposure and associated transmission risk 1

Risk Assessment Factors

• Type of exposure: Different sexual exposures carry different levels of risk 1

  • Highest risk: Receptive anal intercourse
  • Moderate risk: Insertive anal intercourse, receptive vaginal intercourse
  • Lower risk: Insertive vaginal intercourse, oral sex

• Source partner risk factors: Consider if the partner belongs to a high-prevalence group 1

  • Men who have sex with men
  • Injection drug users
  • Commercial sex workers
  • Individuals from high HIV prevalence regions

PEP Recommendations Based on Risk Assessment

1. Known HIV-positive source:

   • Recommend a 28-day course of highly active antiretroviral therapy (HAART) if within 72 hours of exposure 1
   • Start medications as soon as possible for maximum effectiveness 1

2. Unknown HIV status source:

   • No definitive recommendation for or against PEP 1
   • Evaluate risks and benefits on a case-by-case basis 1
   • Consider PEP if the source is from a high-prevalence group and exposure represents substantial risk 1
   • If possible, test the source for HIV status and discontinue PEP if negative 1

3. Low-risk exposure or >72 hours since exposure:

   • PEP is generally not recommended 1
   • Clinicians may consider PEP beyond 72 hours in high-risk exposures if benefits might outweigh risks 1

Medication Regimen

• If PEP is indicated, a 28-day course of HAART is recommended 1
• Medications should be started as soon as possible after exposure 1
• Simpler, less toxic regimens are preferred 2
• Common PEP regimen includes tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) as the backbone 3

Follow-up Care

• Medical evaluation including HIV antibody tests at baseline and periodically for at least 6 months 2
• Monitor for medication toxicity 4
• Provide counseling on medication adherence 4
• Instruct on avoiding secondary transmission 4
• Risk-reduction counseling to prevent future exposures 1

Common Pitfalls to Avoid

• Delayed initiation: PEP effectiveness decreases significantly if started >72 hours after exposure 1, 5
• Poor adherence: Approximately 20% of PEP prescriptions are prematurely discontinued 3
• Inadequate follow-up: Many patients fail to return for follow-up testing 5
• Using PEP for frequent exposures: PEP should not be used for recurrent high-risk behaviors; these individuals should be directed to prevention services and possibly pre-exposure prophylaxis (PrEP) 1, 6

Special Considerations

• Younger patients and men who have sex with men may need additional support for PEP completion and ongoing prevention 3
• Evaluate for other sexually transmitted infections and provide appropriate testing/treatment 4
• Consider hepatitis B vaccination status and need for prophylaxis 7

Remember that PEP is an emergency intervention and should never be considered a primary prevention strategy 2. The best approach to HIV prevention remains avoiding exposure through safer sex practices and other risk-reduction behaviors 1.