Best Post-Exposure Prophylaxis for Needle Stick Injury
For needle stick injuries with risk of HIV exposure, the preferred PEP regimen is bictegravir/emtricitabine/tenofovir alafenamide or dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine), initiated as soon as possible and within 72 hours of exposure. 1
Initial Assessment and Timing
- PEP should be initiated as soon as possible after exposure, ideally within 24 hours, but no later than 72 hours 1
- The initial dose should not be delayed pending laboratory test results 1
- A rapid HIV test or laboratory-based antigen/antibody combination test should be performed on the exposed individual before starting PEP 1
Risk Assessment
- Evaluate the severity of exposure and likelihood of HIV transmission 1
- Consider the HIV status of the source person (if known) and their viral suppression status 1
- PEP is recommended when exposure to nonintact skin or mucous membranes presents a substantial risk for HIV transmission 1
- Exposures to bodily fluids that don't pose significant risk (tears, non-blood-stained saliva, urine, sweat) don't require PEP 1
Recommended PEP Regimens
For Adults and Adolescents:
- First-line regimen: Bictegravir/emtricitabine/tenofovir alafenamide OR dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 1
- Alternative backbone: Tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) or emtricitabine (FTC) 1
- Alternative third drugs: Lopinavir/ritonavir (LPV/r) or atazanavir/ritonavir (ATV/r) 1
For Children ≤10 years:
- Preferred backbone: Zidovudine (ZDV) + lamivudine (3TC) 1
- Preferred third drug: Lopinavir/ritonavir (LPV/r) 1
- Alternative options: Abacavir + 3TC or TDF + 3TC/FTC (backbone); atazanavir/ritonavir, raltegravir, darunavir, efavirenz, or nevirapine (third drug) 1
Duration and Follow-up
- The recommended PEP course is 28 days, regardless of exposure severity 1
- A full 28-day prescription should be provided following initial risk assessment 1
- Follow-up HIV antibody testing at 4-6 weeks and 3 months post-exposure 1
- Enhanced adherence counseling is recommended for all individuals on PEP 1
Additional Prophylaxis Considerations
Hepatitis B Prophylaxis:
- For unvaccinated individuals exposed to HBsAg-positive source: Hepatitis B Immune Globulin (HBIG) 0.06 mL/kg IM immediately and initiate HB vaccine series 2
- For vaccinated individuals with inadequate antibody response: HBIG immediately plus HB vaccine booster 2
Other Considerations:
- Evaluate for sexually transmitted infections if relevant to exposure 1
- Consider hepatitis testing and vaccination as appropriate 1
- Advise exposed individuals to use precautions to prevent secondary transmission during follow-up 1
Special Situations Requiring Expert Consultation
- Delayed exposure report (beyond 24-36 hours) 1
- Unknown source (e.g., needle in sharps container) 1
- Pregnancy in the exposed person 1
- Known or suspected resistance of source virus to antiretroviral agents 1
- Toxicity of the initial PEP regimen 1
Common Pitfalls and Caveats
- Do not delay PEP initiation while waiting for source person's HIV test results 1
- Do not test needles or sharp instruments directly for HIV 1
- PEP failure can occur despite appropriate regimen use, possibly due to drug resistance 3
- PEP is unlikely to be effective when initiated more than 72 hours after exposure 1
- Side effects like nausea and diarrhea are common but can often be managed without changing the PEP regimen 1