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 |
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| + | *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 |
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==Management== |
==Management== |
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*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 |
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| + | *In general, prophylaxis is indicated if the estimated risk is '''greater than 0.1%''' |
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{| class="wikitable" |
{| class="wikitable" |
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| rowspan="2" |substantial |
| rowspan="2" |substantial |
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| − | |HIV-positive with detectable viral load |
+ | |HIV-positive with detectable viral load (100%) |
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| − | |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%) |
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|low but nonzero |
|low but nonzero |
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| rowspan="3" |negligible or none |
| rowspan="3" |negligible or none |
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| − | |confirmed HIV negative |
+ | |confirmed HIV negative (0%) |
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|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 |
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| − | |HIV status unknown, in the general population |
+ | |HIV status unknown, in the general population (0.25%) |
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{| class="wikitable" |
{| class="wikitable" |
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|+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 |
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| align="center" |— |
| align="center" |— |
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| − | |}<br /> |
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| + | |Negligible |
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| + | |Found needle |
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| + | | align="center" |— |
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{| class="wikitable" |
{| class="wikitable" |
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| + | |+Recommended management by source and exposure risk |
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!Risk of HIV-Positive Source |
!Risk of HIV-Positive Source |
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!Risk From Exposure |
!Risk From Exposure |
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|CBC |
|CBC |
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| + | | style="text-align:center;" |X |
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|ALT |
|ALT |
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| + | | style="text-align:center;" |X |
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|repeat at 2 weeks if abnormal |
|repeat at 2 weeks if abnormal |
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|creatinine |
|creatinine |
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| + | | style="text-align:center;" |X |
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|repeat at 2 weeks if abnormal |
|repeat at 2 weeks if abnormal |
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|[[Hepatitis A virus|hepatitis A]] serology |
|[[Hepatitis A virus|hepatitis A]] serology |
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| + | | style="text-align:center;" |X |
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| − | |X |
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|[[Hepatitis B virus|hepatitis B]] serology |
|[[Hepatitis B virus|hepatitis B]] serology |
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| + | | style="text-align:center;" |X |
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| − | |X |
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|includes HBsAb, HBsAg, and HBcAb |
|includes HBsAb, HBsAg, and HBcAb |
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|pregnancy test |
|pregnancy test |
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| + | | style="text-align:center;" |X |
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| − | |X |
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| − | |[[HIV]] serology |
+ | |[[HIV|HIV]] serology |
| + | | style="text-align:center;" |X |
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| − | |X |
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| + | | style="text-align:center;" |X |
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| − | |X |
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|repeat at 6 months if hepatitis C seroconversion |
|repeat at 6 months if hepatitis C seroconversion |
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|[[hepatitis C]] serology |
|[[hepatitis C]] serology |
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| + | | style="text-align:center;" |X |
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| − | |X |
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| + | | style="text-align:center;" |X |
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| − | |X |
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|[[gonorrhea]] and [[chlamydia]] |
|[[gonorrhea]] and [[chlamydia]] |
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| + | | style="text-align:center;" |X |
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| − | |X |
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| + | | style="text-align:center;" |X |
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| − | |X |
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|urine, throat, and rectum, depending on reported sexual activity |
|urine, throat, and rectum, depending on reported sexual activity |
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|[[syphilis]] serology |
|[[syphilis]] serology |
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| + | | style="text-align:center;" |X |
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| − | |X |
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| + | | style="text-align:center;" |X |
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Latest revision as of 14:50, 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 | 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 | 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 | — |
| 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
- 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, hepatitis B, hepatitis C, gonorrhea, chlamydia, and syphilis
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
