B-QuiCK: HIV PEP

B-QuiCK: HIV post-exposure prophylaxis (PEP)

Post-exposure prophylaxis (PEP)

• PEP is fully funded with Special Authority approval for patients who meet the criteria following a non-occupational HIV exposure. It can be prescribed by any relevant practitioner, including general practitioners and nurse practitioners.
  • N.B. Only named specialists (e.g. sexual health or infectious diseases physician) can prescribe PEP for occupational exposures, e.g. needlestick injuries.
• PEP consists of a 28-day course of once daily, oral tenofovir disoproxil 245 mg with emtricitabine 200 mg, with or without dolutegravir 50 mg, depending on the mode of exposure
• Ideally start PEP within 24 hours of the potential exposure, however, it can be initiated up to 72 hours later

Who should receive PEP?

• Assess risk of HIV transmission based on the type of sexual exposure and whether the HIV status of the sexual partner is known (see below)
• General recommendations for deciding whether PEP is required are available here, however, multiple patient factors can influence the risk of HIV transmission
• Prescribe PEP if clearly indicated based on these recommendations and the clinical evaluation below. If uncertain, discuss with an infectious diseases or sexual health physician.

Clinical evaluation of a patient presenting for PEP should include:

The exposure

• When the exposure occurred (date and time)
• Mode of exposure, including factors that may influence or contribute to risk of transmission, e.g. involvement of blood or body fluids, trauma, any first aid that was carried out

Factors that influence the risk of transmission:

• The viral load of the HIV-positive source
• Presence of concurrent STIs
• Any breaches in genital or anal mucosal integrity, e.g. cuts or tears
• If ejaculation occurred during receptive intercourse
• Whether the HIV-negative person is circumcised
• Location of injury and type of needle involved (if needlestick injury)

The patient potentially exposed to HIV

• Date and result of last HIV test
• Any other potential HIV exposures since the patient’s last HIV test
• Alcohol and drug use (current and previous)
• History of PrEP or PEP use
• Current STI status
• Pregnancy risk, contraception and lactation, if applicable (emergency contraception should be offered depending on circumstances)
• Medical history, specifically hepatitis B and C (if present, discuss with a relevant specialist before PEP is prescribed), renal function and psychiatric history
• Current medicines

The source (if it is not possible to establish contact in a timely manner, do not delay prescribing PEP)

• HIV status, if known (and if positive, current viral load)
• General information, e.g. gender, country of origin
• Treatment and medical history, e.g. hepatitis B and C status
• PrEP adherence if relevant

N.B. if necessary, ask the source for consent to contact their general practitioner/other health professional regarding their medical history

Request relevant investigations (but do not delay initiation of PEP)

• Baseline and follow-up HIV test
• Other investigations are determined by mode of exposure, e.g. STI testing for sexual contact (click here)
• Arrange a follow-up appointment for once the course is completed

PEP in patients with impaired renal function

• Avoid tenofovir disoproxil in patients with a creatinine clearance < 50 mL/min
• Discuss these patients with a sexual health or infectious diseases physician (other medicines are available, e.g. zidovudine and lamivudine)

Patient information should be provided when prescribing PEP

• PEP is not 100% effective and must be taken as recommended to have the best chance of success, i.e. initiated within 72 hours of exposure and taken every day at the same time
• Seek medical attention if any symptoms or signs of acute HIV infection, e.g. fever, sore throat, fatigue, headache, rash, myalgia and lymphadenopathy, develop (can occur up to six weeks after exposure or infection may be asymptomatic in some cases)
• Minimise the potential risk of HIV transmission until a negative test result is received, e.g. wearing condoms or abstaining from sexual activity, not sharing injecting equipment, not donating blood
• PrEP may be suitable depending on the patient’s circumstances, and this can be initiated at the completion of the 28-day PEP course