What is the appropriate post‑exposure prophylaxis for a 52‑year‑old woman after an occupational blood exposure?

Post-Exposure Prophylaxis for Occupational Blood Exposure

Immediately initiate a three-drug antiretroviral regimen—preferably bictegravir/emtricitabine/tenofovir alafenamide once daily for 28 days—within 72 hours (ideally within 24 hours) of the blood exposure, while simultaneously testing the source patient for HIV, HBV, and HCV to guide ongoing management. 1

Immediate Actions at the Exposure Site

First, provide wound care:

• Wash the exposure site thoroughly with soap and water if skin was broken 2
• Flush mucous membranes with copious water if eyes or mouth were exposed 2

Do not delay treatment to perform these steps—PEP effectiveness declines with every hour of delay. 1

HIV Post-Exposure Prophylaxis (PEP)

Preferred Regimen

Start bictegravir 50 mg/emtricitabine 200 mg/tenofovir alafenamide 25 mg as a single tablet once daily for 28 days. 1 This regimen offers superior renal and bone safety compared to older formulations. 1

Alternative regimen: Dolutegravir 50 mg once daily plus emtricitabine 200 mg/tenofovir alafenamide 25 mg once daily for 28 days. 1

Critical Timing

• Start PEP within 24 hours if possible, but no later than 72 hours after exposure. 1
• Do not wait for source testing results or detailed risk assessment—start immediately and adjust later if needed. 1
• If the optimal regimen is uncertain, start any available three-drug antiretroviral combination rather than delaying. 1

Baseline Testing Before or Immediately After Starting PEP

• Perform a fourth-generation HIV antigen/antibody combination test on the exposed person 1, 3
• Add HIV nucleic acid test (NAT) if the patient received long-acting injectable PrEP within the past 12 months 1, 3
• Assess baseline renal function (creatinine clearance) to guide tenofovir formulation choice 1
• Screen for other sexually transmitted infections 1
• Test the source patient for HIV antibodies using rapid testing when feasible, but never delay PEP while awaiting these results 1

Duration and Adherence

• Complete the full 28-day course regardless of subsequent source information—incomplete adherence markedly reduces efficacy. 1
• Provide anti-emetics proactively to mitigate nausea and other common side effects 1
• Schedule follow-up within 72 hours to monitor for drug toxicity and reinforce adherence 1, 4

HIV Follow-Up Testing Schedule

• 4–6 weeks: Fourth-generation HIV antigen/antibody test plus HIV NAT 1, 3
• 12 weeks (3 months): Fourth-generation HIV antigen/antibody test plus HIV NAT to definitively confirm negative status 1, 3
• Test immediately if acute retroviral syndrome symptoms develop (fever, rash, lymphadenopathy) 2

Hepatitis B Post-Exposure Prophylaxis

Assess the patient's hepatitis B vaccination history and antibody response status immediately. 2

If the Patient is Unvaccinated or Incompletely Vaccinated:

• Administer hepatitis B immune globulin (HBIG) 0.06 mL/kg intramuscularly as soon as possible 5
• Simultaneously initiate the hepatitis B vaccine series 2, 5
• This combined regimen is 85–95% effective in preventing HBV infection 5

If the Patient is Fully Vaccinated with Known Adequate Response:

• No additional prophylaxis is needed 2

If Vaccination Status is Unknown or Response is Unknown:

• Test for anti-HBs antibody levels 2
• Administer HBIG and/or vaccine based on antibody levels and source patient HBsAg status 2

Hepatitis B Follow-Up

• Test for anti-HBs 1–2 months after the last vaccine dose 2
• Note that anti-HBs response cannot be accurately assessed if HBIG was given within the previous 3–4 months 2

Hepatitis C Post-Exposure Management

No post-exposure prophylaxis is recommended for hepatitis C—there is no effective preventive medication. 2

Hepatitis C Follow-Up Testing:

• Perform baseline anti-HCV antibody and alanine aminotransferase (ALT) testing 2
• Repeat anti-HCV and ALT at 4–6 months post-exposure 2
• Consider HCV RNA testing at 4–6 weeks if earlier diagnosis is desired 2
• Confirm repeatedly reactive anti-HCV enzyme immunoassays with supplemental tests 2

Source Patient Testing

Test the source patient for HBsAg, anti-HCV, and HIV antibody using rapid testing when possible. 2

If the source is unknown or cannot be tested:

• Assess the epidemiologic risk of HBV, HCV, or HIV based on the clinical setting 2
• Never test discarded needles or syringes for virus contamination—this is unreliable and delays care 2, 1

Special Populations

Renal Impairment

• Use tenofovir alafenamide (TAF) rather than tenofovir disoproxil fumarate (TDF) because TAF has minimal renal toxicity. 1

Pregnancy

• Pregnancy does not contraindicate PEP—decisions should be made jointly with the patient, weighing benefits and risks. 1
• Expert consultation is advised but should not delay PEP initiation 1

Breastfeeding

• PEP should not be withheld from breastfeeding individuals. 1
• Discuss temporary cessation of breastfeeding during the 28-day course with expert guidance 1

Counseling and Prevention of Secondary Transmission

Advise the exposed person to:

• Use barrier protection for sexual activity during the follow-up period 2, 1
• Avoid blood, tissue, or organ donation 1
• Seek immediate medical evaluation for any acute illness during follow-up 2, 1

Common Pitfalls to Avoid

• Do not delay PEP while awaiting source testing or detailed risk assessment—start immediately. 1
• Do not use two-drug regimens unless no three-drug options are available. 1
• Do not discontinue PEP early based on later source information—complete the full 28 days. 1
• Do not withhold PEP from pregnant or breastfeeding individuals. 1
• Do not test discarded needles for contamination. 2, 1

Transition to Pre-Exposure Prophylaxis (PrEP)

For persons with anticipated repeat HIV exposures, consider transitioning from PEP to PrEP after completing the 28-day course. 1 Perform HIV testing at the end of PEP before initiating PrEP to confirm seronegative status. 1