Post-exposure prophylaxis for HIV: Difference between revisions

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*Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual
*Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual
*HIV does not survive very long outside of the human body, which is why a random needle in park, for example, is very low risk


== Management ==
==Management==


=== Risk Assessment ===
===Risk Assessment===


* If the source person is available and consents to testing, this can be done to more accurately risk stratify the exposure
*If the source person is available and consents to testing, this can be done to more accurately risk stratify the exposure
*In general, prophylaxis is indicated if the estimated risk is '''greater than 0.1%'''


{| class="wikitable"
{| class="wikitable"
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|-
|-
| rowspan="2" |substantial
| rowspan="2" |substantial
|HIV-positive with detectable viral load
|HIV-positive with detectable viral load (100%)
|-
|-
|HIV status unknown, but from a population with high prevalence such as MSM or PWID
|HIV status unknown, but from a population with high prevalence such as MSM (~23%) or PWID (~13%)
|-
|-
|low but nonzero
|low but nonzero
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|-
|-
| rowspan="3" |negligible or none
| rowspan="3" |negligible or none
|confirmed HIV negative
|confirmed HIV negative (0%)
|-
|-
|HIV positive with confirmed viral load <40 copies/mL without known STI at time of exposure
|HIV positive with confirmed viral load <40 copies/mL without known STI at time of exposure
|-
|-
|HIV status unknown, in the general population
|HIV status unknown, in the general population (0.25%)
|}
|}

{| class="wikitable"
{| class="wikitable"
|+Risk of HIV transmission per act by exposure type from an HIV-positive source
|+Risk of HIV transmission per act by exposure type from an HIV-positive source
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|Blood on compromised skin
|Blood on compromised skin
| align="center" |—
| align="center" |—
⚫
|-
|}<br />
|Negligible
|Found needle
| align="center" |—
⚫
|}

{| class="wikitable"
{| class="wikitable"
|+Recommended management by source and exposure risk
!Risk of HIV-Positive Source
!Risk of HIV-Positive Source
!Risk From Exposure
!Risk From Exposure
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*Don't forget screening for [[Hepatitis A virus|hepatitis A]], [[Hepatitis B virus|hepatitis B]], [[Hepatitis C virus|hepatitis C]], [[gonorrhea]], [[chlamydia]], and [[syphilis]]
*Don't forget screening for [[Hepatitis A virus|hepatitis A]], [[Hepatitis B virus|hepatitis B]], [[Hepatitis C virus|hepatitis C]], [[gonorrhea]], [[chlamydia]], and [[syphilis]]


=== Investigations ===
===Investigations===
{| class="wikitable"
{| class="wikitable"
!Investigation
!Investigation
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|-
|-
|CBC
|CBC
| style="text-align:center;" |X
⚫
|X
|
|
|
|
|-
|-
|ALT
|ALT
| style="text-align:center;" |X
⚫
|X
|
|
|repeat at 2 weeks if abnormal
|repeat at 2 weeks if abnormal
|-
|-
|creatinine
|creatinine
| style="text-align:center;" |X
⚫
|X
|
|
|repeat at 2 weeks if abnormal
|repeat at 2 weeks if abnormal
|-
|-
|[[Hepatitis A virus|hepatitis A]] serology
|[[Hepatitis A virus|hepatitis A]] serology
| style="text-align:center;" |X
|X
|
|
|
|
|-
|-
|[[Hepatitis B virus|hepatitis B]] serology
|[[Hepatitis B virus|hepatitis B]] serology
| style="text-align:center;" |X
|X
|
|
|includes HBsAb, HBsAg, and HBcAb
|includes HBsAb, HBsAg, and HBcAb
|-
|-
|pregnancy test
|pregnancy test
| style="text-align:center;" |X
|X
|
|
|
|
|-
|-
|[[HIV]] serology
|[[HIV|HIV]] serology
| style="text-align:center;" |X
|X
| style="text-align:center;" |X
|X
|repeat at 6 months if hepatitis C seroconversion
|repeat at 6 months if hepatitis C seroconversion
|-
|-
|[[hepatitis C]] serology
|[[hepatitis C]] serology
| style="text-align:center;" |X
|X
| style="text-align:center;" |X
|X
|
|
|-
|-
|[[gonorrhea]] and [[chlamydia]]
|[[gonorrhea]] and [[chlamydia]]
| style="text-align:center;" |X
|X
| style="text-align:center;" |X
|X
|urine, throat, and rectum, depending on reported sexual activity
|urine, throat, and rectum, depending on reported sexual activity
|-
|-
|[[syphilis]] serology
|[[syphilis]] serology
| style="text-align:center;" |X
|X
| style="text-align:center;" |X
|X
⚫
|
|}
|}


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==Further Reading==
==Further Reading==


*Tan ''et al''. [https://doi.org/10.1503/cmaj.170494 Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis]. ''CMAJ'' 2017;189(47):e1448-e1458.
*Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. ''CMAJ''. 2017;189(47):e1448-e1458. doi: [https://doi.org/10.1503/cmaj.170494 10.1503/cmaj.170494]


[[Category:HIV]]
[[Category:HIV]]

Latest revision as of 18:50, 5 July 2022

Background

  • Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual
  • HIV does not survive very long outside of the human body, which is why a random needle in park, for example, is very low risk

Management

Risk Assessment

  • If the source person is available and consents to testing, this can be done to more accurately risk stratify the exposure
  • In general, prophylaxis is indicated if the estimated risk is greater than 0.1%
Risk of HIV-positive source
Risk Examples
substantial HIV-positive with detectable viral load (100%)
HIV status unknown, but from a population with high prevalence such as MSM (~23%) or PWID (~13%)
low but nonzero HIV positive and believed to have undetectable viral load, with concomitant STI at time of exposure
negligible or none confirmed HIV negative (0%)
HIV positive with confirmed viral load <40 copies/mL without known STI at time of exposure
HIV status unknown, in the general population (0.25%)
Risk of HIV transmission per act by exposure type from an HIV-positive source
Risk Exposure Estimated risk per act %
Very high Transfusion 92.5
High Anal (receptive) 1.38
Needle sharing 0.63
Moderate Anal (insertive) 0.11
Vaginal (receptive) 0.08
Vaginal (insertive) 0.04
Low Oral sex (giving) —
Oral sex (receiving) —
Oral-anal contact —
Sharing sex toys —
Blood on compromised skin —
Negligible Found needle —
Recommended management by source and exposure risk
Risk of HIV-Positive Source Risk From Exposure Action
substantial low PEP not required
moderate or high initiate PEP
low low PEP not required
moderate or high consider PEP
negligible or none low PEP not required
moderate or high PEP not required

Antiretroviral Therapy

Investigations

Investigation Baseline Week 12 Notes
CBC X
ALT X repeat at 2 weeks if abnormal
creatinine X repeat at 2 weeks if abnormal
hepatitis A serology X
hepatitis B serology X includes HBsAb, HBsAg, and HBcAb
pregnancy test X
HIV serology X X repeat at 6 months if hepatitis C seroconversion
hepatitis C serology X X
gonorrhea and chlamydia X X urine, throat, and rectum, depending on reported sexual activity
syphilis serology X X

Follow-Up

  • Initial visit; follow-up at 4-6 weeks; then repeat bloodwork at 12 weeks to 4 months
  • Take advantage of the opportunity to counsel patients on STIs, substance use, etc.

Further Reading

  • Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ. 2017;189(47):e1448-e1458. doi: 10.1503/cmaj.170494
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