What are the post-exposure prophylaxis (PEP) medications, specifically post-exposure prophylaxis drugs (antiretroviral medications), for a needlestick injury with potential Human Immunodeficiency Virus (HIV) exposure?

Post-Exposure Prophylaxis Medications for Needlestick HIV Exposure

For needlestick injuries with potential HIV exposure, initiate a three-drug antiretroviral regimen immediately (ideally within 1-2 hours, but no later than 72 hours), with the preferred first-line regimen being bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 1, 2

Preferred PEP Regimens

First-Line Options (Adults and Adolescents)

• Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) - single tablet once daily 1, 2, 3
• Dolutegravir 50mg once daily PLUS emtricitabine/tenofovir alafenamide (FTC/TAF) 200mg/25mg once daily 1, 2, 3

These regimens are preferred because contemporary antiretrovirals are substantially safer and more tolerable than earlier medications, with reduced potential harms from time-limited exposure 1

Alternative Regimens

• Tenofovir disoproxil fumarate (TDF) + lamivudine (3TC) or emtricitabine (FTC) as the backbone, combined with: 3
  • Lopinavir/ritonavir (LPV/r), OR 3
  • Atazanavir/ritonavir (ATV/r) 3

Critical Timing and Duration

• Start PEP as soon as possible - ideally within 1-2 hours, effectiveness decreases significantly after 24-36 hours 2, 3
• Maximum window: 72 hours - PEP is unlikely to be effective when initiated beyond this timeframe 1, 3
• Do NOT delay the first dose while awaiting HIV test results or source person assessment 1
• Complete the full 28-day course regardless of exposure severity 1, 3

Risk Assessment Framework

When PEP is Recommended

• Source known to have HIV with viremia or unknown viral suppression status - PEP is clearly indicated 1
• Percutaneous injury with hollow-bore needle containing blood from HIV-infected source 1
• Deep puncture wounds or visible blood on the device 2
• Needle recently used in a patient's artery or vein 4

Case-by-Case Determination Needed

• Source of unknown HIV status - consider epidemiologic context (high HIV prevalence area, injection drug use setting) 1, 2
• Source with sustained viral suppression - discuss risks versus benefits 1

When PEP is NOT Routinely Recommended

• Found-needle injuries in public settings (parks, playgrounds) - no documented HIV transmissions from discarded needles have occurred; these typically involve small-bore needles exposed to drying with limited blood and low viral viability 1, 4
• Exposure >72 hours ago - evidence insufficient to support efficacy 1
• Source confirmed HIV-negative - discontinue PEP if already started 1

Baseline and Follow-Up Testing Protocol

Before Starting PEP

• Rapid HIV antigen/antibody combination test on the exposed person to rule out pre-existing infection 1, 3
• Do NOT delay first PEP dose while awaiting results 1, 3
• Test source person if available using fourth-generation HIV antigen-antibody test (detects infection earlier than standard antibody tests) 1

Follow-Up Testing Schedule

• 4-6 weeks post-exposure - HIV antibody testing 1, 3
• 3 months (12 weeks) post-exposure - final HIV antibody testing 1, 3
• Advise precautions to prevent secondary transmission during the follow-up period 1

Managing Side Effects and Adherence

Common Side Effects

• Nausea and gastrointestinal symptoms are the most frequent complaints 2, 3
• Management strategies: antiemetics or anti-diarrheal agents can improve adherence 4, 3
• Do NOT stop PEP without medical consultation even if side effects occur 2

Adherence Support

• Consider providing a 3-5 day starter pack initially with scheduled follow-up to assess tolerance and provide full 28-day supply 1
• Enhanced adherence counseling is recommended for all individuals on PEP 3

Special Populations and Situations

Pregnancy

• Do NOT withhold PEP if indicated - discuss potential benefits and risks to woman and fetus 2
• Preferred regimens remain appropriate for pregnant women 1

Renal Impairment

• Use tenofovir alafenamide (TAF) instead of tenofovir disoproxil fumarate (TDF) due to better renal safety profile 2
• Monitor for drug interactions with medications eliminated by active tubular secretion (acyclovir, ganciclovir, aminoglycosides, NSAIDs) which may increase tenofovir concentrations 5

Children and Adolescents

• Three-drug regimens recommended, though two drugs may be considered in certain circumstances 6
• Dosing adjustments based on weight and age - consult pediatric HIV specialist 6, 7

Critical Pitfalls to Avoid

• Never delay PEP beyond 72 hours - effectiveness drops dramatically after this window 1, 2
• Never stop PEP prematurely - the full 28-day course is essential for effectiveness 1, 2
• Never test the needle itself for HIV - this is not reliable or recommended 4, 3
• Never use two-drug regimens for nonoccupational exposures - three-drug regimens are now standard 2, 8
• Never use PEP as substitute for ongoing prevention - if frequent exposures occur, consider pre-exposure prophylaxis (PrEP) instead 1, 4

When to Seek Expert Consultation

Contact the National PEPline at 888-448-4911 for: 1

• Delayed presentation (beyond 24-36 hours) 3
• Unknown source situations 3
• Pregnancy in exposed person 3
• Known or suspected antiretroviral resistance in source 3
• Challenging cases not clearly addressed by guidelines 1

Additional Prophylaxis Considerations

• Evaluate for sexually transmitted infections if exposure was sexual in nature 3
• Consider hepatitis B and C testing and vaccination as appropriate 1, 3
• Assess need for transition to PrEP if ongoing high-risk exposures are anticipated 1