Clinical assessment and follow-up

In making a clinical assessment health practitioners should consider the gender, culture, language and literacy level of the patient, and their intellectual capacity.

The following details should be discussed and documented in the patient’s history:

1. Information about the exposure
  1. Date and time of exposure
  2. Type of exposure, including blood or body fluids involved, trauma, first aid measures applied and any contributory factors.
2. Information about the exposed person
  1. Most recent HIV test and result
  2. Potential exposures within the last three months (or earlier if last HIV test longer than three months ago)
  3. Previous use of PEP or PrEP
  4. Evaluation of current STIs
  5. Hepatitis B (HBV) and C (HCV) infection
    If a patient is known to be HBV or HCV positive, specialist advice should be sought before PEP is commenced. *
  6. Pregnancy risk, contraception and lactation (consider emergency contraception)
  7. Medical history:
    • all medications and drug allergies
    • current and past medical history, e.g. renal disease
    • psychiatric history
    • drug and alcohol history.
3. Information about the source person
Provision of PEP should not be delayed while obtaining this information.
  1. HIV status if known
  2. Demographics factors, e.g. gender, country of origin
  3. If HIV positive:
    • plasma viral load, date of last test, medication adherence
    • antiretroviral treatment history (has resistance been an issue, if so with which drugs?)
    • recent HIV resistance testing
  4. Current STIs; hepatitis B and C status
  5. Whether the source is known to be taking PrEP.
4. PEP discussion

An explanation of PEP and its indications, effectiveness, risks and benefits, potential side effects, potential drug interactions, the importance of 100% adherence to dosing and regimen completion, what to do if a dose is missed.

5. HIV discussion

HIV risk assessment and HIV pre-test information (see National HIV Testing Policy16).

6. Pre-Exposure Prophylaxis (PrEP) discussion

A brief explanation of PrEP for patient consideration and further discussion with a specialist. 

7. Follow-up

The recommended timing of follow-up HIV and other testing is outlined in Table 6 – Individuals found to be HIV positive or indeterminate on baseline testing, or during follow-up, require immediate referral to an HIV specialist.

8. Prescribing and other details

The time of the assessment, regimen prescribed and time of first dose, referral to mental health, risk-reduction counselling or alcohol and other drug (AOD) services if indicated.

*Patients who have already commenced PEP whose baseline serology is consistent with chronic/active hepatitis B and who are on a regimen containing lamivudine, tenofovir or emtricitabine should have LFTs +/- viral load monitored. Advice from a specialist in the management of viral hepatitis should be sought.