What are the post-exposure prophylaxis (PEP) protocols for individuals who experience needle pricks from patients with Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV) infections?

Post-Exposure Management for Needle Stick Injuries from HIV, Hepatitis B, and Hepatitis C

Initiate post-exposure prophylaxis immediately for all three exposures—within 1-2 hours if possible, but no later than 72 hours—using specific protocols for each pathogen, as timing is critical for preventing infection and reducing mortality.

Immediate Actions (Within Minutes to Hours)

For HIV Exposure

• Start antiretroviral PEP with bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) as a single tablet once daily for 28 days immediately, ideally within 1-2 hours but no later than 72 hours post-exposure 1
• Do not delay PEP initiation for any reason—efficacy decreases significantly with each passing hour 1
• Perform rapid HIV antigen/antibody combination test on the exposed person before the first dose, but do not wait for results to start treatment 1, 2
• Check baseline renal function (creatinine, eGFR) before starting any tenofovir-based regimen 1
• Alternative regimen: dolutegravir 50mg once daily plus emtricitabine/tenofovir alafenamide 200mg/25mg once daily for 28 days 1

For Hepatitis B Exposure

• Assess the exposed person's hepatitis B vaccination status and anti-HBs antibody levels immediately 3
• If the exposed person is unvaccinated or incompletely vaccinated: administer hepatitis B immune globulin (HBIG) and initiate or complete the hepatitis B vaccine series 3
• If the exposed person is a known responder to hepatitis B vaccine (anti-HBs ≥10 mIU/mL): no treatment is needed 3
• If the exposed person's response to vaccination is unknown: test anti-HBs levels and administer HBIG if antibody levels are inadequate 3

For Hepatitis C Exposure

• No post-exposure prophylaxis is available or recommended for hepatitis C 3
• Perform baseline HCV antibody and HCV RNA testing on the exposed person 3
• Establish baseline ALT levels for comparison during follow-up 3

Follow-Up Protocols

HIV Follow-Up Testing Schedule

• Evaluate within 72 hours after starting PEP and monitor for drug toxicity for at least 2 weeks 1
• Perform HIV antigen/antibody test plus HIV nucleic acid test (NAT) at 4-6 weeks post-exposure 1
• Repeat laboratory-based HIV antigen/antibody combination immunoassay and HIV NAT at 12 weeks post-exposure 1
• Extended 12-month follow-up is required if the source patient is coinfected with HIV and HCV 4
• Test immediately if acute retroviral syndrome symptoms develop (fever, rash, myalgia, fatigue, malaise, lymphadenopathy), regardless of timeline 4, 3

Hepatitis C Follow-Up Testing Schedule

• Perform HCV antibody testing at baseline, 4-6 weeks, and 3 months post-exposure 3
• Monitor ALT levels at 4-6 weeks and 3 months to detect early hepatitis 3
• Consider HCV RNA testing at 4-6 weeks if earlier diagnosis is desired 3
• If HCV infection is detected, refer immediately for treatment evaluation, as early treatment with direct-acting antivirals can achieve cure rates exceeding 95% 3

Hepatitis B Follow-Up Testing Schedule

• For unvaccinated or incompletely vaccinated persons: test anti-HBs at 6 months to confirm response to vaccination 3
• For persons who received HBIG: test HBsAg and anti-HBs at 6 months 3

Critical Adherence and Counseling Points

HIV PEP Adherence

• Complete the full 28-day course regardless of subsequent information about the source patient, as incomplete adherence significantly reduces effectiveness 1
• Common side effects (nausea, diarrhea, fatigue) can often be managed with antimotility or antiemetic agents without changing the regimen 3
• Provide the full 28-day prescription following initial risk assessment rather than starter packs 2

Secondary Transmission Prevention (First 6-12 Weeks)

• Exercise sexual abstinence or use condoms to prevent sexual transmission and avoid pregnancy 3
• Refrain from donating blood, plasma, organs, tissue, or semen 3
• If breastfeeding, consider discontinuation especially for high-risk HIV exposures 3

Special Situations Requiring Expert Consultation

Contact the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 for 3, 1:

• Delayed exposure report (beyond 24-36 hours)
• Unknown source (e.g., needle in sharps disposal container)—decide PEP on case-by-case basis considering exposure severity
• Known or suspected pregnancy in the exposed person (pregnancy does not preclude optimal PEP regimens)
• Known or suspected resistance of source virus to antiretroviral agents
• Significant toxicity requiring regimen modification

Do not delay PEP initiation while awaiting expert consultation 1

Common Pitfalls to Avoid

• Never test needles or sharp instruments directly for HIV—this is not recommended and delays appropriate care 3, 2
• Do not wait for source patient's HIV test results before starting PEP 2
• Do not deny PEP solely based on pregnancy status 3
• PEP is unlikely to be effective when initiated more than 72 hours after HIV exposure 2
• For hepatitis C, do not administer immune globulin or antiviral prophylaxis—these are not effective 3

Renal Safety Considerations

• Use tenofovir alafenamide (TAF) instead of tenofovir disoproxil fumarate (TDF) in patients with impaired renal function due to improved renal safety profile 1
• Monitor renal function during PEP, especially in patients with baseline renal impairment 1