Is he eligible for Human Immunodeficiency Virus (HIV) post-exposure prophylaxis (PEP)?

HIV Post-Exposure Prophylaxis (PEP) Eligibility Assessment

HIV PEP should be offered and initiated as early as possible, ideally within 72 hours, to any individual with an exposure that has potential for HIV transmission, based on exposure type, source HIV status, and risk assessment. 1

Exposures That Warrant PEP

• PEP is recommended when exposure occurred within the past 72 hours AND presents a substantial risk for HIV transmission AND the source has HIV (without viral suppression) or HIV status is unknown 1, 2
• Eligible exposure types include:
  • Contact with high-risk bodily fluids: blood, blood-stained saliva, breast milk, genital secretions, cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids 1
  • Mucous membrane exposures: sexual contact, splashes to eye, nose, or oral cavity 1
  • Parenteral exposures: needlesticks, sharps injuries, injection drug use equipment sharing 1

Risk Assessment Algorithm

1. Timing of exposure:

   • If ≤72 hours since exposure → continue assessment 1
   • If >72 hours since exposure → PEP generally not recommended, but consider other interventions 1

2. Source HIV status:

   • Known HIV-positive source → recommend PEP 1
   • Unknown HIV status → case-by-case determination based on:
     • Source from high-prevalence group (MSM, PWID, sex workers) → consider PEP 1
     • Local HIV epidemiology and prevalence → influences decision 1
   • Confirmed HIV-negative source → PEP not recommended 1

3. Exposure type:

   • Higher risk: blood transfusion, needle sharing, receptive anal intercourse, percutaneous injuries 1
   • Moderate risk: insertive anal intercourse, penile-vaginal exposures 1
   • Lower risk: oral sex 1
   • No risk: contact with tears, non-blood-stained saliva, urine, sweat → PEP not recommended 1

Important Considerations

• HIV testing of the exposed person should be performed but should not delay PEP initiation 1
• If rapid testing is available, results should be obtained within 2 hours; otherwise, assume person is HIV-negative pending results 1
• PEP should be discontinued if the source is later determined to be HIV-negative 1
• For individuals with frequent, recurrent exposures, PEP is not appropriate; intensive risk-reduction interventions or PrEP should be considered instead 1, 3

Pitfalls to Avoid

• Delaying PEP initiation while awaiting test results can reduce effectiveness 1, 2
• Failing to consider the psychological impact of PEP, which often forces reflection on sexual decision-making 4
• Not recognizing when PEP is inappropriate (e.g., for exposures to non-infectious fluids or when source is confirmed HIV-negative) 1
• Overlooking the need for comprehensive follow-up, including adherence support and toxicity monitoring 5

Follow-up Recommendations

• Complete the full 28-day course of PEP 2
• Follow-up testing at 4-6 weeks and 12 weeks after exposure 2
• For individuals with ongoing risk, consider transitioning directly from PEP to PrEP after completing the PEP course and confirming HIV-negative status 2

HIV PEP eligibility assessment requires rapid evaluation of exposure risk and prompt initiation when indicated, as effectiveness decreases significantly when started beyond 72 hours after exposure 1.