PEP Guidelines

When to prescribe PEP

PEP for Non-Occupational Exposure

Situations where non-occupational PEP should routinely be offered include:

  • Anal or vaginal intercourse (either receptive or insertive) with a partner known to have HIV with an unknown or detectable viral load.
  • Receptive anal intercourse with a source of unknown HIV serostatus from a high prevalence population (MSM, TGD or from HPC).
  • Insertive anal intercourse where the exposed person is uncircumcised, with a source of unknown HIV serostatus from a high prevalence population (MSM, TGD or from HPC).
  • Sharing needles/injecting equipment with a source who is known to have HIV with an unknown or detectable viral load.

Non-occupational PEP should NOT be routinely offered where:

  • The source status is unknown and from a low HIV prevalence setting, such as the general Australian-born heterosexual population
  • The source is a person living with HIV with a non-detectable (<200 copies/mL) HIV viral load
  • The exposure itself poses negligible risk, such as a community needlestick injury or oral sex

Situations where there is greater uncertainty or complexity, such as known or suspected antiretroviral resistance in the source, pregnancy, breastfeeding or chronic hepatitis B or C, should be discussed with a physician experienced in this area.

There is no direct or compelling indirect evidence to support the greater efficacy of three-over two-drug regimens; rather, it has been extrapolated from evidence that a higher number of drugs or combination of drug classes have historically achieved better treatment outcomes for HIV. A summary of the evidence for three-drug versus two-drug PEP is provided in Appendix B.

See Tables 2 and 3 for PEP recommendations.

Where PEP is recommended, it should be prescribed and started as soon as possible after the exposure and within 72 hours.

PEP should generally not be prescribed after 72 hours but may be considered on a case-by-case basis in consultation with a specialist. For very high-risk exposures (e.g. exposure to a source with a known high viral load), three-drug PEP may be considered after 72 hours as it can be continued as very early HIV treatment if seroconversion occurs.

Linkage to a specialist for discussion regarding PrEP should be considered where future HIV risk is likely and/or there have been multiple previous PEP presentations. See the Australian HIV PrEP guidelines for further guidance.

Table 2: PEP recommendations after NON-OCCUPATIONAL exposure

Source HIV status unknownSource knownto have HIV
High prevalence population (MSM, TGD or from HPC)HIV VL undetectableHIV VL detectable or VL unknown
Receptive anal sex with or without ejaculation2 drugsNot recommended3 drugs
Insertive anal sex- uncircumcised2 drugsNot recommended3 drugs
Insertive anal sex-circumcisedConsider 2 drugs*Not recommended3 drugs
Receptive vaginal sex2 drugsNot recommended3 drugs
Insertive vaginal sex2 drugsNot recommended3 drugs
FellatioNot recommended#Not recommended3 drugs
CunnilingusNot recommended#Not recommended3 drugs
Semen splash to the eyeNot recommended#Not recommended3 drugs
Human bitetNot recommended#Not recommended3 drugs
Shared injecting equipment2 drugsConsider 2 drugs3 drugs
Community needle-stick injuryNot recommended#Not recommended3 drugs

Legend

* 2 drugs may be considered if there is a high likelihood of an STI, trauma or blood.
# 2 drugs may be considered only for receptive fellatio WITH ejaculation AND significant visible oral mucosal trauma, or dental and gum disease. 
† 2 drugs may be considered after a bite if: (a) the source (biter’s) saliva or mouth had visible blood, AND (b) there was a high suspicion that the biter was known to have HIV and not taking ART AND (c) the bite has resulted in severe, deep or multiple tissue injuries.

In Table 2 above, the recommended 2-drug PEP regimen is tenofovir disoproxil/emtricitabine 300mg/200mg daily.

The recommended 3-drug PEP regimen is tenofovir disoproxil/emtricitabine 300mg/200mg daily plus dolutegravir 50mg daily.

See What to Prescribe for more detail, including alternative regimens

PEP for Occupational Exposure

In occupational settings, the source is usually able to be identified and tested for HIV. Consent for source testing must be obtained. When the source is incompetent, unconscious or deceased, approval to test the source must be obtained from an authorised person (e.g. Chief Health Officer), as directed in the state or territory legislation.

If the source is at high risk of having HIV and is unable to be tested immediately, the exposed healthcare worker should be commenced on PEP without waiting for the source’s results. If the source is unable to be identified or tested, then the risk of the source having HIV must be assessed from any epidemiological or other information available. The use of PEP should be decided on a case-by-case basis, and it is recommended that an expert is always consulted in this situation.

The risks carried by exposures that occur in the occupational setting are outlined in Table 1. However, the risk is most likely significantly lower than this as these data predate effective antiretroviral therapy (ART). There have not been any reports of occupational HIV transmission in the UK since 1999, and only one in the USA since 1999.25,53 This may be due to a number of factors, including changes in practices to reduce the risk of needlestick injury and a greater proportion of patients on treatment with undetectable viral load. As described above, there is no risk of sexual transmission of HIV when the source has an undetectable viral load (<200 copies/mL).33-36 While it is likely that the same would apply for occupational exposures that most often involve exposure to blood, there is a lack of data to support this. It is reasonable to always offer PEP to a healthcare worker who has had a significant exposure to a source who has HIV, even if the source has an undetectable HIV viral load.

Table 3: PEP recommendations after OCCUPATIONAL exposure

Source HIV status unknownSource known to have HIV
HIV VL detectable or VL unknownHIV VL undetectable*High prevalence population (MSM, TGD or from HPC)
Needlestick injury or other sharps exposure3 drugsConsider 2 drugsConsider 2 drugs
Mucous membrane and non- intact skin exposure3 drugsConsider 2 drugsConsider 2 drugs
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