HIV Postexposure Prophylaxis, Occupational

Postexposure prophylaxis (PEP) is recommended for healthcare personnel who have an occupational exposure to blood, tissue, or other body fluids that may contain human immunodeficiency virus (HIV). ^{[1, 2]}  

Types of exposure that might place healthcare personnel at risk for HIV infection include any of the following ^[3] :

• Percutaneous injury (eg, a needlestick or cut with a sharp object)
• Contact of mucous membranes or non-intact skin (eg, exposed skin that is chapped, abraded, or irritated due to dermatitis) with blood, tissue, or body fluids that are potentially infectious

The following fluids are considered potentially infectious ^{[2, 3]} :

• Semen and vaginal secretions
• Cerebrospinal fluid
• Synovial fluid
• Pleural fluid
• Peritoneal fluid
• Pericardial fluid
• Amniotic fluid

Noninfectious Exposures

The following are not considered potentially infectious unless they are visibly bloody ^{[2, 3]} :

• Feces
• Nasal secretions
• Saliva
• Sputum
• Sweat
• Tears
• Urine
• Vomitus

Treatment Recommendations

HIV PEP should be initiated as soon as possible after the exposure, preferably within hours. Do not delay administration of PEP while awaiting HIV test results of the source patient. The rationale behind this practice includes the following:

• Animal studies demonstrate that PEP is likely to be less effective when started more than 72 hours after exposure. 

• In the abscence of PEP, HIV replication occurs within 48 to 72 hours in regional lymph nodes close to the site of exposure, followed by viremia within 72 to 120 hours of virus inoculation. ^[4]

• If PEP initiation is delayed, the benefits might not outweigh the risks inherent in taking antiretroviral medications.

• Initiating therapy after a longer interval (eg, 1 week) might still be considered for exposures that represent an extremely high risk for transmission.

• The recommended duration of PEP is 4 weeks, given that it appeared protective in in vitro, animal, and occupational studies. If the source patient is determined to be HIV negative, then PEP can be discontinued.

Antiretroviral Drug Regimens

The US Public Health Service (PHS) no longer recommends that the severity of exposure be used to determine the number of drugs to be offered in an HIV PEP regimen. Regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV.  

The HIV status of the exposure source patient should be determined, if possible, to guide the need for HIV PEP. 

Examples of recommended PEP regimens include: a dual nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone plus  an integrase strand transfer inhibitor (INSTI), a ritonavir-boosted protease inhibitor (PI), or a nonnucleoside reverse transcriptase inhibitor (NNRTI). ^[5]

If the source patient has been exposed to antiretroviral agents, and there is potential for drug resistance, consider consultation with a pharmacist or physician who is an expert in HIV and antiretroviral medications to guide the choice of PEP regimen.

Preferred regimens

• Raltegravir 400 mg twice daily  plus  tenofovir disoproxil fumarate/emtricitabine (300mg-200mg) once daily ^{[2, 6]}
• *Dolutegravir 50 mg once daily plus  tenofovir disoproxial fumarate/emtricitabine (300mg-200mg) once daily ^{[4, 7]}  

Lamivudine may be substituted for tenofovir disoproxial fumarate/emtricitabine in either regimen. ^[4]

*The CDC has not updated their guidelines since 2018;8 however, since August 2019, dolutegravir has been considered an acceptable alternative to raltegravir in patients who intend to become pregnant and those who initiate therapy during the first trimester. ^[7]  However, patients should be advised of the small risk for teratogenicity when administered in the first trimester. There is no known elevated risk beyond the first trimester of pregnancy. Non-pregnant individuals of childbearing potential should be counseled about the need for birth control while completing a PEP regimen. ^[4]

The British Association for Sexual Health and HIV (BASHH) 2021 guidelines differ from US guidelines as follows ^[3] :

• Tenofovir disoproxial (TD) 245 mg, fumarate/emtricitabine (FTC) 200 mg, and raltegravir 1200 mg once daily is the regimen of choice.
• For people who are pregnant, raltegravir 400 mg twice daily with TD 245 mg/FTC 200 mg is preferred. 

Alternative regimens

Alternative regimens may combine 1 drug (or drug pair) from the INSTI, PI, or NNRTI classes with 1 pair of NRTIs listed below.

NRTI pairs include the following:

• Tenofovir disoproxil fumarate/emtricitabine
• Tenofovir disoproxil fumarate plus l amivudine
• Zidovudine/lamivudine
• Zidovudine plus emtricitabine

INSTI, PI, or NNRTI options to pair with NRTI options (as listed above) include the following:

• Raltegravir
• Dolutegravir ^{[4, 7]}  
• Darunavir plus ritonavir
• Etravirine
• Rilpivirine
• Atazanavir plus ritonavir
• Lopinavir/ritonavir

Alternative antiretroviral agents for use as PEP only with expert consultation include the following:

• Abacavir - only if negative HLA B57-01 testing
• Efavirenz
• Enfuvirtide - subcutaneous administration
• Fosamprenavir
• Maraviroc
• Saquinavir
• Stavudine

The following antiretroviral agents are generally not recommended for use as PEP given their higher risk for potential toxicities:

• Didanosine
• Nelfinavir
• Tipranavir

The following antiretroviral agent is contraindicated as PEP due to its significant toxicities:

• Nevirapine