- PEP should be initiated as soon as possible and started no later than 72 hours after the exposure, ideally within 24 hours.
- The complete 28-day course of PEP should generally be prescribed and taken daily.
- A five-seven day PEP starter pack remains an option for emergency department presentations.
- In rural and remote settings and other settings where timely specialist advice is unavailable and the clinician cannot determine if, or how many, PEP drugs to prescribe after reviewing Table 2, patients should ideally be prescribed a three-drug starter pack. Where both third recommended PEP drugs are unavailable, prescribe a two-drug starter pack and seek timely specialist review.
- Referral of patients for an in-person or telephone consultation with a specialist PEP provider or prescribing clinician should occur as soon as possible and at least within four weeks of commencing PEP.
- Patients with ongoing HIV acquisition risk and who are agreeable should either be prescribed PrEP immediately or if 3-drug PEP has been prescribed, transitioned immediately from PEP to PrEP.
- If the source individual tests HIV negative on a fourth generation laboratory assay and has had no risk exposures for six weeks, then consideration can be given to discontinue the PEP course.
- Inform all patients of:
- lack of definitive evidence for the efficacy of PEP
- the likelihood that PEP may provide a high level of protection if taken daily for 28 days and initiated promptly
- possible mild transient side-effects and drug-drug interactions
- the importance of follow-up (see Table 4)
- the symptoms of HIV seroconversion and the need for immediate specialist review if they occur
- risk-reduction practices (condoms, clean injecting equipment) until final HIV test completed
- availability of psychosocial support
- transitioning from PEP directly onto PrEP for those at ongoing risk.
Initiation of PEP should occur within 72 hours of exposure to HIV; the earlier the better, and ideally, within 24 hours.
While anecdotal reports suggest potential benefits of emergency 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, there is some contradictory evidence when PEP is prescribed in a specialist setting. 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.25,50
Pre-packaged PEP starter packs of 5-7 days remain an option for emergency department presentations, especially presentations in rural and remote settings where timely specialist advice may not be available.
In rural and remote settings, if the prescriber is uncertain how many PEP drugs should be prescribed (Table 2), it is recommended that the patient ideally be prescribed a three-drug starter pack. If a third recommended drug is not available, a two-drug starter pack may be prescribed. The PEP course can be ceased or modified once a specialist has been consulted. Otherwise, given the high tolerability of current PEP regimens, a complete 28-day supply should be prescribed at first presentation.
At the follow-up consultation, a discussion regarding HIV PrEP should occur (see the National PrEP Guidelines). If exposures are not isolated but ongoing, clinicians should consider offering PrEP immediately. If the person needs a three-drug PEP regimen, the PEP should be prescribed initially and then the individual should be supported to transition to PrEP after 28 days of three-drug PEP. The patient should be referred to an appropriate PrEP prescriber (PrEP prescribers can be located here).
If the source tests negative on a fourth generation laboratory assay and has had no risk exposures for the previous six weeks, then PEP cessation can be discussed with the patient.
Information to provide to patients when initiating PEP
- The lack of definitive evidence for the efficacy of PEP
- With timely initiation, strict medication adherence for 28 days, and avoidance of repeat risk exposures, PEP is likely to provide a high level of protection against HIV acquisition
- Possible mild and short-lived side-effects include nausea, vomiting, diarrhoea, abdominal pain, fatigue and headaches
- Possible drug interactions (see Drug-Drug Interactions with PEP medications)
- The importance of clinical follow-up, including HIV, STI, BBV and pregnancy testing (Table 4)
- The symptoms of HIV seroconversion (fever, sore throat, night sweats, lymphadenopathy, muscular aches and pains, and rash), with advice to urgently access specialist advice if these or any other symptoms occur
- Recommendation to adopt risk-reduction practices (including condoms for vaginal and anal intercourse and sterile injecting paraphernalia) until final HIV testing is complete post PEP completion
- Availability of psychosocial support
- Option for transitioning from PEP directly onto PrEP for those at ongoing risk