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

From the Guidelines

Post-exposure prophylaxis (PEP) treatment should be initiated as soon as possible, ideally within 72 hours after potential exposure to HIV, and the recommended regimen is typically a three-drug combination of tenofovir disoproxil fumarate plus emtricitabine plus either dolutegravir or raltegravir, which should be continued for 28 days, as recommended by the 2020 guidelines of the International Antiviral Society-USA panel 1.

Key Considerations for PEP Treatment

• The effectiveness of PEP decreases with delayed initiation, so immediate medical attention following exposure is crucial for optimal outcomes.
• PEP works by preventing viral replication and establishment of infection in the body.
• During PEP treatment, patients should be monitored for medication side effects, which commonly include nausea, fatigue, and headache.
• Follow-up testing is essential to confirm that infection has not occurred.

Recommended Regimens for PEP

• A three-drug combination of tenofovir disoproxil fumarate 300mg plus emtricitabine 200mg (which can be given as Truvada, one tablet daily) plus either dolutegravir 50mg daily or raltegravir 400mg twice daily is the recommended regimen for HIV PEP, as supported by the 2016 recommendations of the International Antiviral Society-USA panel 1.
• For hepatitis B exposure, hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly and the hepatitis B vaccine series should be administered to unvaccinated individuals.

Special Considerations

• For occupational needlestick injuries, tetanus prophylaxis may also be needed if the patient's vaccination status is not up to date.
• Persons who repeatedly seek PEP should be considered for pre-exposure prophylaxis (PrEP), as daily PrEP may be more protective than repeated episodes of PEP, as suggested by the 2016 guidelines 1.
• The World Health Organization guidelines on postexposure prophylaxis for HIV also recommend a 3-drug regimen for all, given the availability of less toxic and better tolerated medications, as stated in their 2015 guidelines 1.

From the FDA Drug Label

If inadequate antibody,‡ Hepatitis B Immune Globulin (Human) (x1) immediately plus HB Vaccine booster dose, or 2 doses of HBIG,* one as soon as possible after exposure and the second 1 month later. Known Source(High Risk)1. Initiate HB Vaccine Series1 Test Source for HBsAg only if exposed is vaccine nonresponder; if source is HBsAg-positive, give Hepatitis B Immune Globulin (Human) x1 immediately plus HB Vaccine booster dose, or 2 doses of HBIG,* one as soon as possible after exposure and the second 1 month later. All susceptible persons whose sex partners have acute hepatitis B infection should receive a single dose of HBIG (0. 06 mL/kg) and should begin the hepatitis B vaccine series if prophylaxis can be started within 14 days of the last sexual contact or if sexual contact with the infected person will continue.

Postexposure Prophylaxis Treatment:

• For individuals with inadequate antibody, Hepatitis B Immune Globulin (Human) can be administered immediately, along with an HB Vaccine booster dose, or 2 doses of HBIG, one as soon as possible after exposure and the second 1 month later 2.
• For individuals exposed to a known source (high risk), the treatment depends on the source's HBsAg status and the exposed individual's vaccination status.
• For sexual exposure to an HBsAg-positive person, a single dose of HBIG (0.06 mL/kg) and initiation of the hepatitis B vaccine series are recommended if prophylaxis can be started within 14 days of the last sexual contact or if sexual contact with the infected person will continue 2.

From the Research

Post-Exposure Prophylaxis Treatment

• Post-exposure prophylaxis (PEP) is a treatment used to prevent HIV acquisition after exposure to the virus 3.
• PEP has been recommended for over three decades, but remains underutilized globally 3.
• Clinical trials have established the safety and tolerability of newer PEP regimens, particularly those containing integrase strand transfer inhibitors (INSTIs) combined with a tenofovir and lamivudine or emtricitabine backbone 3.

Types of PEP Regimens

• INSTIs combined with a tenofovir and lamivudine or emtricitabine backbone are effective and well-tolerated PEP regimens 3.
• Ritonavir-boosted darunavir combined with raltegravir or tenofovir-emtricitabine is also a treatment option for patients with CD4 cell counts higher than 200 cells per μL 4.

Guidelines and Recommendations

• Consensus documents and guidelines have been developed to promote the appropriate use of PEP, including recommendations for assessing the risk of transmission, special circumstances to consider, and patterns of antiretroviral therapy 5.
• The strength of the recommendation and gradation of evidence are based on the GRADE system 5.
• NPs play an essential role in managing treatment for people exposed to HIV and following up on these patients' response and adherence to the treatment protocol 6.

Challenges and Future Directions

• Despite the increase in well-tolerated options, PEP seems to be underused globally, and links to other prevention services are suboptimal 3.
• Interventions to increase provider and community awareness of PEP are needed 3.
• The continuous evolution of antiretrovirals and the associated update of clinical practice guidelines create a challenge for NPs caring for patients exposed to HIV 6.