PEP Guidelines

Prescribing PEP

Important note for healthare workers  who have not previously prescribed HIV PEP

Traditionally, the medication used for 2-drug PEP – tenofovir disoproxil 300mg /emtricitabine 200mg (TD/FTC) – was only available from emergency departments, sexual health clinics, HIV specialists, or other accredited HIV s100 prescribers. However, due to the widespread uptake of PrEP, generic formulations of TD/FTC are now also available in many community pharmacies. This makes it possible for any prescriber to provide a private prescription for TD/FTC as 2-drug PEP at a reasonable cost. (At the time of publication, approximately $40–$50 for a one-month course). The medications used are not Therapeutic Goods Administration (TGA)–approved or PBS–listed for PEP, therefore, a private prescription for TD/FTC with no repeats must written.

Please follow the guidelines outlined in this document to assess if your patient fits the recommendation for 2-drug PEP and, if unsure, contact your local PEP telephone support line. If 2-drug PEP is indicated and the individual is considering starting PrEP for likely ongoing HIV exposures, a 3-month prescription for PrEP (TD/FTC 30 tablets with two repeats) can be offered, as PrEP and 2-drug PEP are the same medication. Alternatively, write a private prescription for PEP (TD/FTC 30 tablets, no repeats) and arrange follow-up.

As PEP medication comes in 30-day supplies, prescriptions can be written for 30 days. Advise the individual to take the medication for 28 days and keep the remaining two tablets. This allows for the immediate commencement of PEP should they have a future exposure.

Generic formulations are not currently available for dolutegravir, the current recommended third drug used for PEP. If the individual requires 3-drug PEP, please consult your local PEP phone line for advice on where to access dolutegravir.

Local telephone support is available here for PEP prescribing in each Australian jurisdiction.

Provide the full course at first presentation

Previously, anecdotal reports suggested potential benefits with the use of starter packs, including clinical review within the first week to ensure completed baseline pathology and to allow modification of inappropriate or poorly tolerated PEP regimens. However, a systematic review and meta-analysis of outcomes of PEP initiation using starter packs (versus dispensing the full 28-day course) suggested that starter packs do not improve acceptance and may negatively affect completion of PEP, with almost 30% of those provided with a starter pack not returning for follow-up.29,59

PEP starter packs for 5 to 7 days remain an option for emergency department presentations, especially presentations in rural and remote and low PEP presentation settings, where timely specialist advice may not be available. In some settings, starter packs may contain all three drugs, with patients receiving either two or three drugs depending on the exposure. 

If 3-drug PEP is recommended and the third drug is not available, 2-drug PEP may be initially prescribed. Contact the PEP phoneline in your state or the closest PEP providing site for advice on where to obtain the third drug.

What to prescribe

The current recommended first-line 2-drug regimen is co-formulated tenofovir disoproxil 300mg and emtricitabine 200mg (TD/FTC) taken once daily. This regimen is ideal for PEP because it is well tolerated with good anogenital tissue penetration.60 In addition, TD/FTC is now available in affordable, generic forms.

Where a third drug is required, dolutegravir is recommended.

2-drug regimen

Tenofovir disoproxil* 300mg /emtricitabine 200mg (daily) for 28 days

3-drug regimen

Tenofovir disoproxil* 300mg /emtricitabine 200mg (daily) for 28 days

PLUS

Dolutegravir 50mg (daily) for 28 days

If dolutegravir is unsuitable due to drug interactions use raltegravir 1200 mg daily (see Table 5)

Legend

* There are four salts of tenofovir disoproxil available with slightly different dosages, which are considered bioequivalent: maleate, phosphate, fumarate and succinate
In general, tenofovir disoproxil and emtricitabine with dolutegravir is well tolerated when taken as PEP.21,28,29,31,32,61,62

If a patient reports intolerable or serious side effects from a previous PEP course or has an e-GFR < 60mL/min:

  • An alternative PEP regimen should ideally be prescribed (discuss with specialist or PEP phone line).
  • In emergency (out-of-hours) situations (unless previously reported side-effects were serious), the available PEP regimen should be prescribed with urgent specialist follow-up arranged to monitor the PEP regimen.

Medications and cautions

Table 5: Specific medications and cautions

MedicationComments and cautions
Tenofovir disoproxil

  • Use with caution or avoid in renal disease (eGFR <60), consult specialist for alternative (tenofovir alafenamide) if eGFR <60.

  • Avoid high doses of non-steroidal anti-inflammatory drugs (NSAIDs) during use.


  • Where tenofovir is directly contraindicated, seek expert advice.

Dolutegravir

  • Phenytoin, phenobarbital, rifampicin, St John’s Wort, and carbamazepine all reduce dolutegravir levels. If unable to cease above medications, use raltegravir 1200mg daily.


  • If taking antacids containing polyvalent cations (e.g. magnesium or aluminium), take the antacid at least 2 hours before or 6 hours after the dolutegravir dose.


  • Products containing calcium or iron should be taken at least 2 hours before or 6 hours after the dolutegravir dose OR dose concomitantly with food.


  • If taking metformin, increase monitoring of glycaemic control - an adjustment of metformin dose may be required.
Raltegravir

  • There is a small risk of rhabdomyolysis – inform patients about the potential for myalgia and the need to re-present if myalgia occurs.
  • Caution patients who engage in heavy gym work about the increased risk of rhabdomyolysis, especially when anabolic steroids are used.


  • Check creatine kinase (CK), renal function, and urinary myoglobin in patients who report myalgia on raltegravir.


  • Advise against the use of statins while on PEP containing raltegravir.

Adverse Events

Proximal renal tubular dysfunction (including Fanconi syndrome) has been reported among people with HIV on tenofovir disoproxil-containing therapy,63 but has not been reported among patients prescribed a 28-day PEP course.

Myopathy or severe rhabdomyolysis has been reported, albeit rarely, with use of dolutegravir and raltegravir.64-67 It is advised that:

  • Patients on PEP should be monitored for symptoms.
  • Caution should be taken among those with a history of myopathy, or with co-administration with medications such as statins,68 which may also cause myopathy.
  • Creatine kinase (CK), renal function and urinary myoglobin should be checked in patients who report significant myalgia.
  • Potential Drug-Drug interactions can be checked using the Liverpool HIV Drug interaction checker.
Scroll to Top