What HIV post‑exposure prophylaxis and STI preventive regimen should I start after a condom break during unprotected sex one hour ago, with no symptoms, no medical history, and no current medications?

Immediate Management After Condom Rupture During Sex

Start HIV post-exposure prophylaxis (PEP) immediately with bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) as a single daily tablet for 28 days, and arrange STI screening and hepatitis B prophylaxis. 1, 2

HIV Post-Exposure Prophylaxis (PEP)

Immediate Action Required

• Initiate PEP now—you are within the critical 72-hour window, and every hour of delay reduces effectiveness. 3, 1, 2
• The optimal timing is within 24 hours of exposure, and you are currently at approximately 1 hour post-exposure, which is ideal. 1, 2
• Do not wait for HIV test results or additional information about your partner's status before starting medication. 3, 2

Recommended PEP Regimen

First-line regimen: Bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg (BIC/FTC/TAF) as a single tablet once daily. 1, 2

Alternative regimen (if BIC/FTC/TAF unavailable): Dolutegravir 50mg once daily PLUS emtricitabine/tenofovir alafenamide 200mg/25mg once daily. 1, 2

• These integrase inhibitor-based regimens are preferred because they have superior tolerability, fewer side effects, and better completion rates compared to older regimens. 2, 4
• The single-tablet formulation improves adherence over the 28-day course. 2

Duration and Adherence

• Complete the full 28-day course regardless of any subsequent information you obtain about your partner's HIV status. 3, 1, 2
• Incomplete adherence significantly reduces effectiveness—missing doses compromises protection. 2
• Common side effects include nausea and fatigue; anti-nausea medication can be prescribed proactively to help you complete the course. 3, 2

Baseline Testing (Do Not Delay Treatment)

Perform these tests today, but start PEP first:

• Rapid HIV antibody or antigen/antibody combination test to document your baseline HIV-negative status. 1, 2
• Baseline testing for other sexually transmitted infections (gonorrhea, chlamydia, syphilis). 2, 5
• Hepatitis B and C screening. 3, 1
• Pregnancy test if applicable. 3

Follow-Up Testing Schedule

• 4-6 weeks post-exposure: HIV antigen/antibody test PLUS HIV nucleic acid test (NAT). 1, 2
• 12 weeks post-exposure: Laboratory-based HIV antigen/antibody combination immunoassay AND HIV nucleic acid test (NAT) for final clearance. 1, 2
• Seek immediate medical evaluation if you develop fever, rash, sore throat, or flu-like symptoms during follow-up, as these may indicate acute HIV infection. 2

STI Prevention and Screening

Bacterial STI Prophylaxis

While the evidence focuses primarily on HIV PEP, you should also receive:

• Screening for gonorrhea, chlamydia, and syphilis at baseline and again at 4-6 weeks. 3, 2
• Consider empiric treatment for gonorrhea and chlamydia if your partner's STI status is unknown and you are in a high-prevalence area (discuss with your provider). 3

Hepatitis B Prophylaxis

• If you are not vaccinated against hepatitis B, start the hepatitis B vaccine series today. 3, 5
• If your partner is known to have hepatitis B or is at high risk, you may also need hepatitis B immunoglobulin (HBIG) in addition to vaccination. 3

Hepatitis C Screening

• Hepatitis C testing is recommended when exposure involved blood contact or if your partner is at high risk for hepatitis C. 1
• Repeat hepatitis C testing at follow-up visits. 3

Risk Assessment Context

Your case warrants PEP because:

• The exposure occurred within 72 hours (you are at 1 hour, which is optimal). 3, 1, 5
• Condom breakage during penetrative sex represents substantial risk for HIV transmission if your partner is HIV-positive or from a high-prevalence population. 3, 5
• When your partner's HIV status is unknown, CDC guidelines recommend case-by-case evaluation, and given the substantial transmission risk from unprotected intercourse, PEP is warranted. 3, 5

Prevention Counseling and Next Steps

• Use condoms or abstain from sex during the 28-day PEP course and 12-week follow-up period to prevent secondary transmission and reinfection. 2
• If you anticipate ongoing high-risk exposures, discuss transitioning to pre-exposure prophylaxis (PrEP) after completing PEP and confirming HIV-negative status at 12 weeks. 3, 1, 2
• Schedule a follow-up visit within 3-5 days to review baseline test results, assess medication side effects, and reinforce adherence. 3, 2

Critical Pitfalls to Avoid

• Never delay PEP initiation for source testing, risk assessment, or baseline test results—start immediately. 3, 2
• Do not stop PEP early even if you later learn your partner is HIV-negative; complete the full 28 days once started. 2
• Do not use PEP as a substitute for ongoing prevention—if you have recurrent high-risk exposures, you need PrEP instead. 3, 5
• Ensure you have adequate follow-up scheduled; loss to follow-up is a common failure point. 2