What is the approach for a patient with potential HIV exposure through body fluids?

Approach to HIV/Body Fluid Exposure

Initiate post-exposure prophylaxis (PEP) with a three-drug antiretroviral regimen immediately—ideally within 24 hours but no later than 72 hours after exposure—for any substantial risk exposure to blood, semen, vaginal secretions, rectal secretions, breast milk, or blood-contaminated body fluids. 1, 2

Immediate Assessment (Within Minutes to Hours)

Step 1: Provide Wound Care

• Wash wounds and skin with soap and water 3
• Flush mucous membranes (eyes, nose, mouth) with water 3
• Do not squeeze or manipulate the wound 3

Step 2: Rapid Risk Assessment

Determine if exposure warrants PEP by evaluating:

High-risk exposures requiring PEP: 3, 1

• Blood or blood-stained fluids
• Semen, vaginal secretions, rectal secretions
• Breast milk
• Cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids
• Via mucous membrane, percutaneous injury, or parenteral routes

Exposures NOT requiring PEP: 3, 2

• Tears, non-blood-stained saliva, urine, feces, vomitus, sputum, nasal secretions, sweat
• When exposed person is already HIV-positive
• When source is confirmed HIV-negative

Step 3: Baseline Testing (Do NOT Delay PEP)

Test the exposed person: 3, 1, 2

• Perform rapid HIV antibody or fourth-generation antigen-antibody combination test
• Start PEP immediately without waiting for results 3, 1
• If patient received long-acting injectable PrEP in past 12 months, add HIV nucleic acid test (NAT) 2

Test the source person (if available): 3, 1

• Fourth-generation HIV antigen-antibody test preferred (detects infection earlier than standard antibody tests) 3
• If source tests negative and has no acute HIV symptoms, discontinue PEP 3
• Do not delay PEP initiation while awaiting source testing 3, 2

PEP Initiation (Within 72 Hours Maximum)

Timing is Critical

The 72-hour window is absolute: 3, 1

• Efficacy decreases dramatically with each passing hour 2
• Ideally start within 24 hours 1, 2
• Maximum benefit when started within 48-72 hours 3
• After 72 hours, PEP is generally not recommended unless clinician judges diminished benefit outweighs risks 3

Preferred PEP Regimens

First-line regimen (United States): 2

• Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) - single daily tablet
• Dose: Bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg once daily 2
• Superior renal and bone safety compared to older regimens 2
• Higher completion rates due to single-tablet formulation 2, 4

Alternative regimen: 2

• Dolutegravir 50mg once daily PLUS emtricitabine/tenofovir alafenamide (FTC/TAF) 200mg/25mg once daily 2
• Can substitute tenofovir disoproxil fumarate (TDF) 300mg if TAF unavailable, though TAF preferred for renal safety 2

WHO-recommended regimen (international settings): 3

• TDF + 3TC (or FTC) as backbone PLUS lopinavir/ritonavir (LPV/r) or atazanavir/ritonavir (ATV/r) 3

Duration

Complete full 28-day course regardless of any subsequent information about source patient 3, 2

• No option for early discontinuation 2
• Incomplete adherence significantly reduces effectiveness 2

Additional Essential Interventions

Test for Co-Infections

Screen for sexually transmitted infections at baseline: 3

• STIs increase risk of HIV acquisition 3
• Provide STI prophylaxis as indicated 3

Hepatitis B assessment: 3

• Test for hepatitis B surface antigen 3
• Vaccinate if not immune 3
• Provide hepatitis B immunoglobulin (HBIG) if indicated 3

Hepatitis C testing: 3

• Baseline anti-HCV and ALT 3
• Follow-up at 4-6 months 3

Emergency Contraception

For women with genital exposure to semen, discuss emergency contraception 3

Follow-Up Schedule

Monitoring During PEP Course

Within 72 hours after starting PEP: 2

• Clinical evaluation for drug toxicity 3, 2
• Assess adherence and provide support 2
• Provide anti-emetics or supportive medications proactively for nausea/fatigue 2

Every 2 weeks during 28-day course: 3

• Monitor for adverse effects 3
• Assess medication adherence 2

Post-PEP HIV Testing Schedule

At 4-6 weeks: 3, 2

• HIV antigen-antibody test PLUS HIV nucleic acid test (NAT) 2

At 12 weeks (3 months): 3, 2

• Laboratory-based HIV antigen-antibody combination immunoassay AND HIV NAT 2

At 6 months (if using older antibody-only tests): 3

• Final HIV antibody test 3

Immediate testing if acute illness develops: 3, 2

• Fever, rash, myalgias, or other symptoms suggesting acute retroviral syndrome 3, 2

Special Considerations

Unknown Source HIV Status

When source HIV status unknown: 3

• Weigh risks and benefits on case-by-case basis 3
• Consider background HIV prevalence and epidemiological patterns 3
• In high-prevalence settings, may offer PEP without extensive risk assessment 3

Pregnancy

Pregnancy does not preclude PEP use 2

• Use optimal regimens without modification 2
• Consult expert if needed but do not delay initiation 2

Renal Impairment

Use tenofovir alafenamide (TAF) instead of tenofovir disoproxil fumarate (TDF) 2

• TAF has improved renal and bone safety profiles 2

Bite Injuries

HIV transmission by bites is rare 3

• Saliva contaminated with blood poses substantial risk 3
• Non-bloody saliva constitutes negligible risk 3

Needle Stick from Discarded Needles

Risk is lower than fresh needles but not negligible 3

• Small-bore needles contain limited blood 3
• Viral viability decreases rapidly: <1% viable virus after 1 week at higher temperatures 3
• Still consider PEP if within 72 hours and source likely HIV-positive 3

Counseling and Prevention

During Follow-Up Period

Advise precautions to prevent secondary transmission: 3, 2

• Use barrier protection during sex 3
• Avoid blood/body fluid exposure to others 3
• Do not donate blood, plasma, organs, tissue, or semen 3

Transition to PrEP

For persons with ongoing HIV risk after completing PEP: 3, 1, 2

• Consider immediate transition from PEP to pre-exposure prophylaxis (PrEP) 1, 2
• Perform HIV testing at completion of 28-day PEP course before starting PrEP 2
• Offer to those who received nPEP in past year 3

Risk Reduction Counseling

Provide substance abuse treatment referrals for injection drug users 3

• Instruct on sterile syringe use for each injection 3
• Refer to needle exchange programs where available 3

Common Pitfalls to Avoid

Never delay PEP for: 3, 1, 2

• HIV test results 3, 1
• Source person testing or risk assessment 3, 2
• Insurance authorization 2

Do not use two-drug regimens unless three-drug options absolutely unavailable 3, 2

Do not test discarded needles or syringes for virus contamination 3

Do not stop PEP early even if source later confirmed HIV-negative 2