There may be several reasons a patient may decline PEP, including:
- personal risk assessment not based on current evidence, or clinician recommendation
- concern about medication side-effects
- concern about longer-term toxicity
- lack of awareness about the use and likely efficacy of PEP.
If the exposure is one where PEP is recommended, clinicians should discuss patient concerns and provide information, including:
- the likelihood of HIV acquisition from the exposure (Appendix A)
- the presumed high rate of efficacy against acquiring HIV when taken soon after exposure and as prescribed
- the usually mild and short-lived side-effects with current recommended PEP medications
- the available option of stopping or modifying PEP agents if side-effects do occur
- the current need for lifelong antiretroviral therapy if diagnosed with HIV, in contrast to 28 days of PEP
- the lack of evidence of long-term toxicity associated with a 28-day course of PEP
- the need to consistently use condoms until the patient has a negative follow-up HIV test.
Advice for tor those who still decline PEP following a high-risk exposure:
- the maximum 72-hour window-period for starting a PEP course
- have follow-up HIV testing (see National HIV Testing Policy)
- monitor for HIV seroconversion symptoms: most commonly (in order of decreasing prevalence): fever, fatigue, myalgia, skin rash, headache, pharyngitis, cervical adenopathy, arthralgia, night sweats, and diarrhoea96
- return for assessment if any symptoms are present.
Additionally, the clinician should:
- provide contact information for access to medical care if the exposed person decides to pursue PEP
- offer a referral for psychological support
- clearly document the refusal of PEP in the exposed person’s medical record.