PEP Guidelines: Quick-Reference
| Estimated risk of HIV transmission/exposure*Source A known HIV positive (Refer to tables in Appendix A) | Source of unknown HIV status (Refer to tables in Appendix A) |
|||
|---|---|---|---|---|
| HIV VL unknown or detectable | HIV VL undetectable | Very high prevalence population B (MSM who injects drugs) | High prevalence population B (MSM or from HPC) | |
| Sexual exposure C,D | ||||
| Receptive anal sex | 3 drug | NR | 3 drug | 2 drug |
| Insertive anal sex Uncircumcised | 3 drug | NR | 3 drug | 2 drug |
| Insertive anal sex Circumcised | 3 drug | NR | 3 drug | NR |
| Receptive vaginal sex | 3 drug | NR | 3 drug | NR |
| Insertive vaginal sex | 3 drug | NR | 3 drugs | NR |
| Fellatio | NR# | NR | NR# | NR# |
| Cunnilingus | NR | NR | NR | NR |
| Semen splash into eye | NR | NR | NR | NR |
| Occupational and other exposuresE | ||||
| Shared injecting equipment | 3 drug | Consider 2 drug | 3 drug | 2 drug |
| Occupational needle-stick injury | 3 drug | Consider 2 drug | 3 drug | NR |
| Mucosal exposure/splash injury to infectious fluids | 3 drugs | NR | 3 drug | NR |
| Human bite E | NR | NR | NR | NR |
| Community needle-stick injury | NR | NR | NR | NR |
Figure 1: Recommended regimens for PEP
STANDARD REGIMEN Two-drug regimen: Tenofovir disoproxil* /emtricitabine 200 mg 1 tablet orally daily Three-drug regimen: above two-drug regimen PLUS Dolutegravir 50 mg 1 tablet orally daily OR (alternative) Raltegravir 1200 mg (2 X 600 mg tablets orally daily) ALTERNATIVE REGIMEN IN RENAL IMPAIRMENT^ If eGFR < 30 mL/min: seek specialist HIV and renal advice immediately If eGFR = 30-49 mL/min: use the following dosages58 |
Tenofovir disoproxil one tablet orally every 48 hours PLUS Emtricitabine one tablet orally every 48 hours OR lamivudine 150 mg orally daily PLUS (if three-drug PEP indicated) Dolutegravir 50 mg orally daily OR raltegravir 1200 mg orally daily |
NO DOSE ADJUSTMENTS NECESSARY FOR ANY RECOMMENDED REGIMENS IN HEPATIC IMPAIRMENT58 |
* There are four salts of tenofovir disoproxil available with slightly different dosages in combination with emtricitabine which are considered bioequivalent: maleate, phosphate, fumarate and succinate
^eGFR: estimated glomerular filtration rate
eGFR is recommended to be calculated by Cockcroft Gault equation :58 Creatinine Clearance Calculator
^ alternative dosing with emtricitabine oral solution or tenofovir disoproxil granules may be used where available; for dosage guide refer to: Liverpool HIV Drug Interactions checker website.
Table 4. Laboratory assessment of people who are prescribed PEP
| Test | Baseline | Week 4-6i | Week 12 |
|---|---|---|---|
| HIV (HIV Ag/Ab test) a | X | X | X |
| Hepatitis B (HBV) (HBsAg, Anti-HBs and Anti-HBc) b,c | X | X |
|
| Hepatitis C Hepatitis C (HCV) antibody ± HCV RNA Qual PCR d | X X | X | X |
| Chlamydia and gonorrhoea e | X | X | X |
| Syphilis serology f | X | X | X |
| EUC (including eGFR) h | X | See h | |
| Pregnancy test g | X | X |
a 4th generation HIV antigen/antibody combination test
b HBsAg –HBV surface antigen; Anti-HBs – HBV surface antibody; Anti-HBc – HBV core antibody
c See section: Management of possible exposure to other conditions: HBV
d HCV RNA Qual PCR – Qualitative HCV RNA polymerase chain reaction (PCR) – reflex testing by laboratories following positive HCV Ab test should occur at baseline only if history of past HCV; consider PCR at 4-6 weeks for all occupational exposures, for medico-legal purposes including sexual assault, or for percutaneous exposures if source HCV status is positive or unknown
e See section: Management of possible exposure to other conditions: STIs
f Chemiluminescent Microparticle Immunoassay (CMIA) or Enzyme Immunoassay (EIA); if reactive, laboratories generally perform reflex confirmatory testing and Rapid Plasma Reagin (Venereal Disease Research Laboratory) (RPR [VDRL]) staging
gAssess for risk of pregnancy, perform BHCG serology and consider emergency contraception
hRepeat EUC if abnormal at baseline and/or clinically indicated; eGFR should ideally be calculated using the Cockcroft Gault method73
i At a week-4 visit, assess for transition directly to HIV PrEP.
