What is the recommended regimen for HIV non-occupational post-exposure prophylaxis (nPEP)?

Recommended Regimen for HIV Non-Occupational Post-Exposure Prophylaxis (nPEP)

The preferred regimens for HIV nPEP in adults and adolescents without contraindications are bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) or dolutegravir (DTG) plus tenofovir alafenamide (TAF) or tenofovir disoproxil fumarate (TDF) plus emtricitabine (FTC) or lamivudine (3TC). 1

Key Principles of nPEP

• nPEP should be initiated as soon as possible after exposure, ideally within 72 hours 1
• The recommended duration of nPEP is 28 days 1
• nPEP is recommended when there is substantial risk for HIV transmission and the source is known to have HIV without viral suppression or unknown viral suppression status 1
• A case-by-case determination is needed when exposure presents substantial risk but the source's HIV status is unknown 1

Preferred Regimens for Adults and Adolescents

First-line options:

• Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) - available as a single tablet complete regimen 1
• Dolutegravir (DTG) plus (tenofovir alafenamide [TAF] OR tenofovir disoproxil fumarate [TDF]) plus (emtricitabine [FTC] OR lamivudine [3TC]) 1

Alternative regimen:

• Darunavir/cobicistat/tenofovir alafenamide/emtricitabine (DRV/c/TAF/FTC) 1

Regimen Selection Considerations

• Renal function: TAF is preferred over TDF in patients with impaired renal function 1
• Drug interactions: Assess for potential interactions with concurrent medications 1
• Previous ARV exposure: Consider different regimen if patient has history of ARV exposure 1
• Source patient factors: Consider source's treatment history and potential resistance patterns if known 1
• Pregnancy status: Some regimens may be contraindicated in pregnancy 1

Pediatric nPEP Regimens

Children aged ≥2 years to 12 years:

• Preferred: Integrase strand transfer inhibitors PLUS two nucleoside reverse transcriptase inhibitors
  • Bictegravir/emtricitabine/tenofovir alafenamide (≥14 kg) OR
  • Dolutegravir PLUS (tenofovir alafenamide OR tenofovir disoproxil fumarate) PLUS (emtricitabine OR lamivudine) 1

Infants and children aged ≥4 weeks to 2 years:

• Preferred: Dolutegravir (>3 kg) PLUS zidovudine PLUS (emtricitabine OR lamivudine) 1

Laboratory Testing and Monitoring

• At initial visit: Rapid or laboratory-based antigen/antibody combination HIV test 1
• For persons with recent long-acting injectable PrEP exposure: Add HIV nucleic acid test (NAT) 1
• Interim testing: HIV Ag/Ab test plus HIV NAT at 4-6 weeks post-exposure 1
• Final testing: Laboratory-based HIV Ag/Ab combination immunoassay and HIV NAT at 12 weeks post-exposure 1

Follow-up and Transition to PrEP

• Evaluate exposed persons taking nPEP within 72 hours after exposure 1
• Monitor for drug toxicity for at least 2 weeks 1
• Consider transition to PrEP after completing nPEP for persons with ongoing HIV exposure risk 1
• Perform HIV testing at completion of nPEP before transitioning to PrEP 1

Common Pitfalls and Caveats

• Delayed initiation: Efficacy decreases with time; initiate as soon as possible after exposure 1
• Poor adherence: Side effects may reduce adherence; consider supportive medications (antiemetics, antimotility agents) if needed 1
• Incomplete regimens: Three-drug regimens are now preferred over two-drug regimens for all exposures 2
• Inadequate follow-up: Ensure proper HIV testing schedule is followed 1
• Missing drug interactions: Always check for potential interactions with current medications 1

The evolution of nPEP regimens has moved from older zidovudine-based combinations to more tolerable tenofovir-based regimens, with integrase inhibitors now preferred as the third agent due to better tolerability and fewer drug interactions 2, 3.