Post-exposure prophylaxis for HIV: Difference between revisions

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==Background==
= HIV post-exposure prophylaxis (PEP) =


*Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual
== Exposures ==
*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==
* Can be sexual or non-sexual; consensual or non-consensual; and heterosexual or homosexual


== 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
{|
*In general, prophylaxis is indicated if the estimated risk is '''greater than 0.1%'''
! Level

! Exposure
{| class="wikitable"
!align="center"| Estimated risk per act %
|+Risk of HIV-positive source
!Risk
!Examples
|-
|-
| rowspan="2" |substantial
| Very high
|HIV-positive with detectable viral load (100%)
| Transfusion
|align="center"| 92.5
|-
|-
|HIV status unknown, but from a population with high prevalence such as MSM (~23%) or PWID (~13%)
| High
| Anal (receptive)
|align="center"| 1.38
|-
|-
|low but nonzero
|
|HIV positive and believed to have undetectable viral load, with concomitant STI at time of exposure
| Needle sharing
|align="center"| 0.63
|-
|-
| rowspan="3" |negligible or none
| Moderate
|confirmed HIV negative (0%)
| Anal (insertive)
|align="center"| 0.11
|-
|-
|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%)
|}

{| class="wikitable"
|+Risk of HIV transmission per act by exposure type from an HIV-positive source
!Risk
!Exposure
! align="center" |Estimated risk per act %
|-
|Very high
|Transfusion
| align="center" |92.5
|-
| rowspan="2" |High
|Anal (receptive)
| align="center" |1.38
|-
|Needle sharing
| align="center" |0.63
|-
| rowspan="3" |Moderate
|Anal (insertive)
| align="center" |0.11
|-
|Vaginal (receptive)
| align="center" |0.08
|-
|Vaginal (insertive)
| align="center" |0.04
|-
| rowspan="5" |Low
|Oral sex (giving)
| align="center" |—
|-
|Oral sex (receiving)
| align="center" |—
|-
|Oral-anal contact
| align="center" |—
|-
|Sharing sex toys
| align="center" |—
|-
|Blood on compromised skin
| align="center" |—
|-
|Negligible
|Found needle
| align="center" |—
|}

{| class="wikitable"
|+Recommended management by source and exposure risk
!Risk of HIV-Positive Source
!Risk From Exposure
!Action
|-
| rowspan="2" |substantial
|low
|PEP not required
|-
|moderate or high
|initiate PEP
|-
| rowspan="2" |low
|low
|PEP not required
|-
|moderate or high
|consider PEP
|-
| rowspan="2" |negligible or none
|low
|PEP not required
|-
|moderate or high
|PEP not required
|}

===Antiretroviral Therapy===

*Screen for sexual assault, counsel about safe sex
*Screen for pregnancy and get baseline investigations (below)
*Start antiretroviral therapy within '''72 hours''' and continue for 28 days
**First-line: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[raltegravir]] 400 PO bid
**Alternative: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[dolutegravir]] 50 mg PO daily
**Alternative: [[tenofovir disoproxil fumarate]]/[[emtricitabine]] 300 mg/200 mg PO daily plus [[darunavir]]/[[ritonavir]] 800 mg/100 mg PO daily
*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===
{| class="wikitable"
!Investigation
!Baseline
!Week 12
!Notes
|-
|CBC
| style="text-align:center;" |X
|
|
|
| Vaginal (receptive)
|align="center"| 0.08
|-
|-
|ALT
| style="text-align:center;" |X
|
|
|repeat at 2 weeks if abnormal
| Vaginal (insertive)
|align="center"| 0.04
|-
|-
|creatinine
| Low
| style="text-align:center;" |X
| Oral sex (giving)
|
|align="center"| —
|repeat at 2 weeks if abnormal
|-
|-
|[[Hepatitis A virus|hepatitis A]] serology
| style="text-align:center;" |X
|
|
|
| Oral sex (receiving)
|align="center"| —
|-
|-
|[[Hepatitis B virus|hepatitis B]] serology
| style="text-align:center;" |X
|
|
|includes HBsAb, HBsAg, and HBcAb
| Oral-anal contact
|align="center"| —
|-
|-
|pregnancy test
| style="text-align:center;" |X
|
|
|
| Sharing sex toys
|align="center"| —
|-
|-
|[[HIV|HIV]] serology
| style="text-align:center;" |X
| style="text-align:center;" |X
|repeat at 6 months if hepatitis C seroconversion
|-
|[[hepatitis C]] serology
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|-
|[[gonorrhea]] and [[chlamydia]]
| style="text-align:center;" |X
| style="text-align:center;" |X
|urine, throat, and rectum, depending on reported sexual activity
|-
|[[syphilis]] serology
| style="text-align:center;" |X
| style="text-align:center;" |X
|
|
| Blood on compromised skin
|align="center"| —
|}
|}


===Follow-Up===
== Investigations ==

* HIV testing at baseline and 12 weeks
* HAV-Ab, HBsAg/sAb/cAb at baseline
* HCV-Ab at baseline and 12 weeks
* Gonorrhea and chlamydia of urine, throat, and rectum at baseline and 12 weeks
* Sypthilis at baseline and 12 weeks
* CBC at baseline
* ALT and creatinine at baseline, repeated at 2 weeks if abnormal
* Pregnancy test at baseline

== Treatment ==

* Screen for sexual assault, counsel about safe sex
* Start treatment within 72 hours
* Tenofovir/emtricitabine 300/200 with raltegravir 400 BID, for 28 days
** Preferred alternatives include TDF/FTC with darunavir/ritonavir or dolutegravir
** Other alternatives include many
* Don't forget above screening


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


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


*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]
== Further Reading ==


[[Category:HIV]]
* 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.

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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