HIV Postexposure Prophylaxis (PEP), Nonoccupational (nPEP) 

Updated: Jan 15, 2019
  • Author: Jason F Okulicz, MD, FACP, FIDSA; more...
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HIV Postexposure Prophylaxis, Nonoccupational

Several guidelines and recommendations for prevention, screening, diagnosis, treatment, and management of human immunodeficiency virus (HIV) infection have been issued by the Centers for Disease Control and Prevention (CDC) and other federal government agencies. [1] The purpose of nonoccupational postexposure prophylaxis (nPEP) is to reduce the risk of infection. Nonoccupational exposure refers to exposure to an infectious agent that occurs outside the workplace (eg, during sex or during the sharing of needles to inject drugs). The CDC’s recommendations for antiretroviral postexposure prophylaxis (PEP) after sexual, injection-drug use, or other nonoccupational HIV exposure in the United States are summarized below. [2]

CDC guidelines for occupational exposures have been recently updated and are summarized in HIV Postexposure Prophylaxis, Occupational.

Recommendations

A 28-day course of antiretroviral therapy (ART) is recommended in persons who have had a nonoccupational exposure that represents a substantial risk for HIV transmission and when the person seeks care within 72 hours of exposure. When indicated, antiretroviral nPEP should be initiated promptly for the best chance of success.

Healthcare providers should evaluate persons rapidly for nPEP when care is sought ≤72 hours after a potential nonoccupational exposure that presents a substantial risk for HIV acquisition. All persons considered for nPEP should undergo HIV testing to determine HIV infection status, preferably with rapid combined Ag/Ab, or antibody blood tests. If rapid HIV blood test results are unavailable and nPEP is otherwise indicated, it should be initiated without delay and can be discontinued if the patient is later determined to be HIV-positive already or the source is found to be HIV-negative.

nPEP is recommended when the source of the body fluids is known to be HIV-positive and the reported exposure presents a substantial risk for transmission.

nPEP is not recommended when the reported exposure presents no substantial risk for HIV transmission.

nPEP is not recommended when care is sought > 72 hours after the potential exposure.

A case-by-case determination about nPEP is recommended when the HIV infection status of the source of the body fluids is unknown and the reported exposure presents a substantial risk for transmission if the source is HIV-positive.

All persons offered nPEP should be prescribed a 28-day course of a 3-drug antiretroviral regimen (see below).

The preferred regimen for otherwise healthy adults and adolescents is as follows:

  • Tenofovir disoproxil fumarate (tenofovir DF or TDF) (300 mg) with emtricitabine (200 mg) once daily plus
  • Raltegravir (RAL) 400 mg twice daily or dolutegravir (DTG) 50 mg daily

Healthcare providers prescribing PEP should avoid DTG in (1) nonpregnant women of childbearing potential who are sexually active or have been sexually assaulted and who are not using an effective birth control method and (2) pregnant women early in pregnancy, since the risk of an unborn infant developing a neural tube defect is during the first 28 days. The preferred nPEP regimen in these women is raltegravir, tenofovir, and emtricitabine. However, individual circumstances may dictate consideration of alternatives (eg, if raltegravir is unavailable). Healthcare providers seeking advice can call the National Clinical Consultations Center’s PEPline at (888) 448-4911.

An alternative regimen in otherwise healthy adults and adolescents is as follows:

  • Tenofovir DF (300 mg) with emtricitabine (FTC) (200 mg) once daily plus
  • Darunavir (DRV) (800 mg) and ritonavir (RTV) (100 mg) once daily

Healthcare providers considering using antiretroviral regimens for nPEP other than those listed in these guidelines as preferred or alternative are encouraged to consult with other healthcare providers who have expertise in antiretroviral medication use for similar patients (eg, children, pregnant women, or patients with comorbid conditions such as impaired renal function).

Any indicated prevention, treatment, or supportive care for other exposure-associated health risks and conditions (eg, bacterial sexually transmitted infections, traumatic injuries, hepatitis B virus and hepatitis C virus infection, or pregnancy) should be provided to all persons evaluated for possible nPEP .

All persons who report behaviors or situations that place them at risk for frequently recurring HIV exposures (eg, injection drug use, sex without condoms) or who report receipt of  ≥1 course of nPEP in the preceding year should receive risk-reduction counseling and intervention services, including consideration of preexposure prophylaxis (PrEP).